APPLICATION FOR COMMUNITY BASED

DRUG REHABILITATION PROGRAM

ACCREDITATION
BARANGAY WANGAN
City of Davao
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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

TRANSMITTAL LETTER

October 1, 2024

ANNABELLE P. YUMANG, MD, MCH, CESO III

Regional Director
Department of Health
Davao Center for Health Development
J. P. Laurel Avenue, Bajada,
Davao City

THRU: SAMSIA S. SANDUKAN, RSW

DDAPTP Regional Coordinator
Dangerous Drugs Abuse and Prevention Treatment program
Senior Health program Officer (SHPO)
Outpatient and Aftercare Center for Drug Dependence
Dear Ma’am:
Assalamu alaikum!

Hope all is well.

As part of the requirements for Barangay Drug Clearing in the CHO/ DOH which is the CBDRP Accreditation of each barangay.
I am transmitting to your good office the 2 folders of BARANGAY Wangan for your kind reference.
All the attachments sent to your email address earlier and as per our conversation via sms and messenger, all the required documents
have been complied and completely attached to this folder.
Hope for your kind consideration to issue our CBDRP Certificate for Barangay Wangan

Please acknowledge receipt hereof.

Very truly yours,

HON. DANILO M. ABABON JAFFAR U. MAROHOMSALIC

Barangay Chairman CADAC Action Officer

____________________________________________________________________________________________
Annex A- DOH Department Memorandum 2021-0521

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 “Interim Guidelines for the Certification of Community-based Drug Rehabilitation Program”

Republic of the Philippines

City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District
_________________________________________________________________________________________________________________________

Annex A- DOH Department Memorandum 2021-0521

“Interim Guidelines for the Certification of Community-based Drug Rehabilitation Program” Annex A

CHECKLIST FOR CERTIFICATION OF CBDRP PROGRAMS

I. Name of Community Based Drug Rehabilitation Program: BARANGAY WANGAN

A. City of Davao
B. Barangay Anti-Drug Abuse Council Focal Person: HON. DANILO M. ABABON
C. Email: barangaywangan@gmail.com
D. Contact Number: 0967-803-1193 / 0935-081-5059

II. Date of Certification:__________________________________________

A. Certified by: _____________________________________________
B. Tittle/ Position, Office: ___________________________________
C. Contact Number: __________________________________________
Instruction: Please put a tick on each criterion complied with during validation.

CBDRP CERTIFICATION CRITERIA/

PUBLIC HEALTH COMPONENT SERVICES
CHECKLIST FOR VALIDATION

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1. PROMOTION I. Any of the following PROMOTION
a. Knowledge on causes, ill effects, and Consequences of
services from (a) to (d):
substance use and misuse.
b. Advocacy towards a healthy lifestyle free from a. IEC materials, OR
drugs and other gateway substances (i.e. tobacco
and alcohol) b. Brochures, ORu
c. Advocacy towards healthy relationships with
family, friends, and community c. Protocols
Advocacy towards health-seeking behavior to
Remarks:
prevent prog

d. ression of risky behavior

2. PREVENTION I. Certification of Completion
a. Screening Services – Screening Brief on
Intervention and Referral to Treatment
(SBIRT) and Testing SBIRT Training, AND

II. Screening tool materials

Remarks:

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 3. TREATMENT for Moderate Risk for Drug 1. Certificate of Completion
Dependence and/or Mild Substance Use
of Training, AND
Disorder
a. Counseling for both individuals and the 2. Schedule of Activities
family

Remarks:
4. REFERRALS for High Risk for Drug 1. Memorandum of Agreement for each of (a) to
Dependence and with co-morbidities
(d)
a. Assessment of Services- DDE by DOH-accredited
physician a. Assessment services
b. Treatment referral to Non-residential or
b. Treatment referral
Outpatient DATRC/ Recovery Clinic and Residential
DATRC
to Non-Residential
c. Treatment referral to psycho-socio-spiritual services
. Treatment referral of psychiatric and medical
comorbidities to specialty services in
DATRC and
hospitals
Residential DATRC’s
c. Treatment referral

to psycho-socio-

spiritual services
d. Treatment referral of
psychiatric and
medical comorbidities
to specialty services in hospitals
Remarks:

5|P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

TAB A

PROMOTION
(IEC Materials, Brochures, Protocols)

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

TO : BARANGAY ANTI DRUG ABUSE COUNCIL MEMBERS

ALL PUNONG BARANGAY (BADAC CHAIRMAN)

FROM : JAFFAR U. MAROHOMSALIC

Action Officer – CADAC

DATE : September 11, 2023

Greetings!
1. Pursuant to Presidential Proclamation No. 264 of 1988 entitled
Declaring the 26th of June every year as the INTERNATIONAL DAY
AGAINST DRUG ABUSE AND ILLICIT TRAFFICKING (IDADAIT). This
declaration is in support of the resolution passed by the United Nations
(UN) General Assembly on Dec 7, 1987.

2. The theme of this year’s observance is “People First: Stop Stigma and
Discrimination, Strengthen Prevention”, which was circulated by the
UN Office on Drugs and Crime (UN ODC) for adoption by all member-
countries.

3. This year’s event aims to:

a. Identify the responsibilities of the government and different sectors
in the fight against the drug problem;
b. Create awareness on the dangers and ill-effects of dangerous drugs;
c. Develop peer support networks among service providers and drug
dependents beneficiaries; and
d. Promote unity within the advocacy of treatment and preventive
education

4. As member of the Municipal/ Barangay Anti-Drug Abuse Council

pursuant to Section II of DILG Memorandum Circular No. 2015-63 and
Section I of Dangerous Drugs Board Regulation No. 3, Series of 2017,
the Local Government Unit is enjoined to support the observance of
IDADAIT.

5. In view of this, the M/BADAC and other concerns are encouraged to

support this event by undertaking appropriate, relevant and related
activities which are geared towards the attainment of the goals by way

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 of promoting the event and the campaign message through the
following:
a. Conduct of Activities like Seminars and Advocacies;
b. Hoisting Streamers/ banners in strategic places in the barangay
vicinity, and
c. Posting of the event and its theme on electronic billboard or website
of the Local Government Unit

6. Expenses incurred relative to the conduct of activities for the said

celebration shall be charged to local funds, subjects to the usual
accounting and auditing rules and regulations.

7. Immediate dissemination of this letter is desired.

For any concerns, please contact the Floro M. Castillo, CADAC Focal with
phone number: 225-1216/225-0102

For your guidance.

JAFFAR U. MAROHOMSALIC
Action Officer

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

POST ACTIVITY REPORT

ACTIVITY: CONDUCT OF FAMILY PREVENTIVE DRUG ABUSE

EDUCATION SEMINAR

DATE: July 26, 2024

VENUE BARANGAY WANGAN

PARTICIPANTS PUROK LEADERS , REFORMISTS FAMILY & BAT

MEMBERS

The Barangay Anti-Drug Abuse Council headed by Punong Barangay DANILO M. ABABON facilitated the
CONDUCT FAMILY PREVENTIVE DRUG ABUSE EDUCATION SEMINAR with the CADAC personnel. The
program aims to establish a family-focused prevention strategy, to strengthen the understanding the risks
associated with drug use and its impact on both physical and mental health, and be able to identify where to
seek help if someone in the family is struggling with substance abuse and empower families to create a
supportive environment.
Speakers were Mr. Floro Castillo CADAC Technical Adviser and Mr. Jeff Anthony Vasquez CADAC Supervisor.
Mr Floro Castillo emphasized the importance of FAMILY prevention and drug abuse education. The family
plays crucial role in drug abuse prevention, family members usually keep an eye to other members’ behavior,
the first individual to understand and emphasize and safeguard against misuse of the substance. It is proper
to involve families of PWUDS as they play a role as protective shield against substance misuse and help them
focus in their goal of transformation and cope up for healthier life.

Prepared by :

CYNTHIA L. MALAQUE
Barangay Secretary
Approved and attested by:
HON. DANILO M. ABABON
Punong Baranga

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

POST ACTIVITY REPORT

ACTIVITY: ORIENTATION ON BADAC AUXILIARY TEAM

DATE: July 12, 2024

VENUE BARANGAY WANGAN

PARTICIPANTS Barangay Council, BADAC Members, and BAT

Members

The Barangay Anti-Drug Abuse Council headed by Punong Barangay DANILO M. ABABON, Punong Barangay
conducted Orientation on BADAC AUXILLIARY TEAM with the facilitators from CADAC, Mr. Floro
Castillo III, CADAC Technical Adviser and Mr. Jeff Anthony Vasquez, CADAC Supervisor.

Police Corporal April Maguinsay refresh possible scenarios that a BADAC Auxiliary has to remember, in responding
barangay chaos, Ensure safety of yourself she added, while ensuring safety of the community. When you respond
make sure that your life will not be jeopardized. Must remember, the procedures like handcuffing, usage of the
baton. Must be knowledgeable of the Barangay Ordinances.

Prepared by:
CYNTHIA L. MALAQUE
Barangay Secretary
Approved and attested by: DANILO M. ABABON
Punong Barangay

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

ACTIVITY: CONDUCT OF INFORMATION & EDUCATION CAMPAIGN

DATE: July 26, 2024
VENUE BARANGAY FUNCTION HALL
PARTICIPANTS Barangay Council, Reformist and House Cluster

BADAC spearheaded by Punong Barangay Danilo M. Ababon, conducted

INFORMATION & EDUCATION CAMPAIGN, Mr. Floro Castillo CADAC Technical Adviser and Mr.
jeff Anthony Vasquez CADAC Supervisor. Mr Floro Castillo emphasized the importance of sustaining
the Drug Cleared Barangay Status, awareness, and education. Campaign Materials that will equip
every constituents with the knowledge and know specific details on how to prevent illegal drugs.
Information Dissemination is an important factor for everyone to be vigilant. Well informed individuals
are significant in the battle of ensuring our community from the ill effects of Drug Addiction.

Prepared by:

CYNTHIA L. MALAQUE
Barangay Secretary
Approved and attested by:

DANILO M. ABABON
Punong Barangay

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

TAB B

PREVENTION
(SBIRT Training Certificate and Screening Tool
Materials)

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

SBIRT TRAINING CERTIFICATE

ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

SBIRT TRAINING CERTIFICATE

ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

SBIRT TRAINING CERTIFICATE

ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

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 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

Alcohol Smoking and Substance Involvement Screening Test (ASSIST)

and Self-Reporting Questionnaire (SRQ)- Filipino Version
Tool developed by the World Health Organization

Translated by the USAID Renew Health Project

Nag-iinterview: Bansa: Tanggapan:

Pangalan ng Petsa at
ini-interview Oras

Pagpapakilala (Basahin sa kliyente)

Maraming salamat sa iyong pagpayag na makibahagi sa maikling interview na ito ukol sa paggamit ng uri ng
psychoactive substances (droga, alkohol, sigarilyo). May mga katanungan ako tungkol sa iyong mga
karanasan sa paggamit ng mga ito sa iyong buong buhay, lalo na sa nakaraang tatlong buwan. Ang mga ito
ay maaaring hinihithit, nilulunok, sinisinghot, tinuturok, o iniinom sa anyo ng tabletas.

Ang ilan sa mga nakalista ay maaaring inireseta ng doktor (tulad ng amphetamines, sedatives (pampakalma),
at pain medications (pang alis ng sakit)). Para sa interbyu na ito, hindi ko isusulat ang mga gamot na iyong
iniinom na iniriseta ng iyong doktor. Pero kung ininom mo ang mga gamot na ito na hindi naireseta o ininom
mo ng mas madalas o mas mataas kaysa sa inireseta ng doktor, pakisabi mo sa akin. Kahit ako ay
interesadong malaman ang iyong paggamit ng ipinagbabawal na gamot, sinisigurado kong walang sinumang
makakaalam nito.

Bago magtanong, ibigay sa kliyente ang ASSIST response card

Tanong 1 (T1)
Kung kinukumpleto ang follow up, pakikumpara ang mga sagot ng kliyente sa pinakaunang sagot niya
sa parehong tanong sa baseline. Linawin kung may pagkakaiba.
Sa buong buhay mo, alin sa mga sumusunod ang nasubukan Hindi Oo
mo nang gamitin? (di-medikal na paggamit lamang)

a. Produktong tabako (sigarilyo, nganga, tabako, 0 6

atbp) 3
a. Inuming nakakalasing (beer, alak, atbp) 0 3
b. Cannabis (marijuana, damo, halaman, five fingers, 0 3
omads,
c. joint, roach,
Cocaine chongkee,
(coke, crack, maryjane,
rocks, ice,MJ,
kokajutes, ganja, atbp)
atbp) 0 3
d. Amphetamine type stimulants (speed, diet pills, ecstasy, 0 3
Bangkok pills, X, love drug, hug drug, happy pills, MDA, XTC,
eckie, lovedoves, adam or eden tablet, yuppy drug, atbp)
e. Sinisinghot (nitrous, rugby, glue, petrol, paint thinner, atbp) 0 3
f. Pampakalma o Pampatulog (Valium, Pinoy X, 0 3
Dormikum, Serepax, Rohypnol, atbp)
g. Hallucinogens (LSD, Shrooms, magic shrooms, kabute, 0 3
Ketamine, atbp)

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 h. Opioids (Nubain, Heroin, Morphine, Methadone, 0 3
Codeine, atbp)
i. Kung may iba pa, pakibanggit: 0 3

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 Kung “Hindi” ang kasagutan sa lahat ng
tanong, itigil ang interview.
Kung ang sagot sa lahat ng katanungan ay "hindi",
magtanong Kung “oo” ang sagot sa mga nabanggit,
Hal. Hindi rin kahit noong nag-aaral ka pa? pumunta sa T2 para sa bawat psychoactive
substance na nagamit na

Tanong 2 (T2)

kailanman

Araw-araw
Dalawang
Sa nakaraang tatlong buwan, gaano kadalas mong nagamit ang

Beses

buwan

linggo
Isa o

Linggo-
Hindi

Buwan-
mga sumusunod na substances na nabanggit mo
(una, ikalawang droga, atbp)?

a. Produktong tabako (sigarilyo, nganga, tabako, atbp) 0 2 3 4 6

b. Inuming nakakalasing (beer, alak, atbp) 0 2 3 4 6
c. Cannabis (marijuana, damo, halaman, five fingers, omads, 0 2 3 4 6
joint, roach, chongkee, maryjane, MJ, jutes, ganja, atbp)
d. Cocaine (coke, crack, rocks, ice, koka atbp) 0 2 3 4 6
e. Amphetamine type stimulants (speed, diet pills, ecstasy, 0 2 3 4 6
Bangkok pills, X, love drug, hug drug, happy pills, MDA,
XTC, eckie, lovedoves, adam or eden tablet, yuppy
drug, atbp)
f. Sinisinghot (nitrous, rugby, glue, petrol, paint thinner, atbp) 0 2 3 4 6
g. Pampakalma o Pampatulog (Valium, Pinoy X, Dormikum, 0 2 3 4 6
Serepax, Rohypnol, atbp)
h. Hallucinogens (LSD, Shrooms, magic shrooms, kabute, 0 2 3 4 6
Ketamine, atbp)
i. Opioids (Nubain, Heroin, Morphine, Methadone, Codeine, 0 2 3 4 6
atbp)
j. Kung may iba pa, pakibanggit: 0 2 3 4 6

Kung “Hindi kailanman” ang sagot sa lahat ng tanong, pumunta sa T6

Kung alin man sa T2 ay nagamit mo sa nakaraang talong buwan magpatuloy sa T3, T4 at T5 para sa
bawat psychoactive substances na ginamit.

Tanong 3 (T3)

Araw-araw
kailanman

Dalawang

Sa nakaraang 3 buwan, gaano ka kadalas na nakaramdam ng

Beses

buwan

linggo
Linggo-
Hindi

Buwan-
Isa o

matinding pagnanais na gumamit ng mga nabanggit mo? (una,

ikalawang droga, atbp)

a. Produktong tabako (sigarilyo, nganga, tabako, atbp) 0 3 4 5 6

b. Inuming nakakalasing (beer, alak, atbp) 0 3 4 5 6
c. Cannabis (marijuana, damo, halaman, five fingers, omads, 0 3 4 5 6
joint, roach, chongkee, maryjane, MJ, jutes, ganja, atbp)
d. Cocaine (coke, crack, rocks, ice, koka atbp) 0 3 4 5 6
e. Amphetamine type stimulants (speed, diet pills, ecstasy, 0 3 4 5 6
Bangkok pills, X, love drug, hug drug, happy pills, MDA,
XTC, eckie, lovedoves, adam or eden tablet, yuppy
drug, atbp)
f. Sinisinghot (nitrous, rugby, glue, petrol, paint thinner, atbp) 0 3 4 5 6
g. Pampakalma o Pampatulog (Valium, Pinoy X, Dormikum, 0 3 4 5 6
Serepax, Rohypnol, atbp)
h. Hallucinogens (LSD, Shrooms, magic shrooms, kabute, 0 3 4 5 6
Ketamine, atbp)
i. Opioids (Nubain, Heroin, Morphine, Methadone, Codeine, 0 3 4 5 6
atbp)

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 j. Kung may iba pa, pakibanggit: 0 3 4 5 6

Tanong 4 (T4)

kailanman

Araw-araw
Sa nakaraang 3 buwan, gaano ka kadalas nakararanas ng

Dalawang
Beses

buwan

linggo
Linggo-
Hindi

Buwan-
problemang pang-kalusugan, sosyal, legal o pinansyal dahil sa

Isa o
mga nabanggit mong psychoactive substances? (una,
ikalawang droga, atbp)
a. Produktong tabako (sigarilyo, nganga, tabako, atbp) 0 4 5 6 7
b. Inuming nakakalasing (beer, alak, atbp) 0 4 5 6 7
c. Cannabis (marijuana, damo, halaman, five fingers, 0 4 5 6 7
omads, joint, roach, chongkee, maryjane, MJ,
jutes, ganja, atbp)
d. Cocaine (coke, crack, rocks, ice, koka atbp) 0 4 5 6 7
e. Amphetamine type stimulants (speed, diet pills, ecstasy, 0 4 5 6 7
Bangkok pills, X, love drug, hug drug, happy pills, MDA,
XTC, eckie, lovedoves, adam or eden tablet, yuppy
drug, atbp)
f. Sinisinghot (nitrous, rugby, glue, petrol, paint thinner, 0 4 5 6 7
atbp)
g. Pampakalma o Pampatulog (Valium, Pinoy X, Dormikum, 0 4 5 6 7
Serepax, Rohypnol, atbp)
h. Hallucinogens (LSD, Shrooms, magic shrooms, kabute, 0 4 5 6 7
Ketamine, atbp)
i. Opioids (Nubain, Heroin, Morphine, Methadone, Codeine, 0 4 5 6 7
atbp)
j. Kung may iba pa, pakibanggit: 0 4 5 6 7

Tanong 5 (T5)

Araw-araw
kailanman

Sa nakaraang tatlong buwan, gaano kadalas mong hindi

Dalawang
Beses

buwan

linggo
Linggo-
Hindi

nagampanan ang mga inaasahan sa iyo dahil sa paggamit mo Buwan-

Isa o

ng mga nabanggit mong psychoactive substances? (una,

ikalawang droga, atbp)
a. Produktong tabako (sigarilyo, nganga, tabako, atbp) 0 5 6 7 8
b. Inuming nakakalasing (beer, alak, atbp) 0 5 6 7 8
c. Cannabis (marijuana, damo, halaman, five fingers, 0 5 6 7 8
omads, joint, roach, chongkee, maryjane, MJ,
jutes, ganja, atbp)
d. Cocaine (coke, crack, rocks, ice, koka atbp) 0 5 6 7 8
e. Amphetamine type stimulants (speed, diet pills, ecstasy, 0 5 6 7 8
Bangkok pills, X, love drug, hug drug, happy pills, MDA,
XTC, eckie, lovedoves, adam or eden tablet, yuppy
drug, atbp)
f. Sinisinghot (nitrous, rugby, glue, petrol, paint thinner, 0 5 6 7 8
atbp)
g. Pampakalma o Pampatulog (Valium, Pinoy X, Dormikum, 0 5 6 7 8
Serepax, Rohypnol, atbp)
h. Hallucinogens (LSD, Shrooms, magic shrooms, kabute, 0 5 6 7 8
Ketamine, atbp)
i. Opioids (Nubain, Heroin, Morphine, Methadone, Codeine, 0 5 6 7 8
atbp)
j. Kung may iba pa, pakibanggit: 0 5 6 7 8

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 Itanong ang T6 at T7 para sa lahat ng psychoactive substances na nagamit na ng kliyente (na “oo” ang
sagot sa T1).

Tanong 6 (T6)

tatlong buwan

tatlong buwan
Oo, pero hindi
sa nakaraang
nakaraang
kailanman

Oo, sa
May kaibigan o kamag-anak ka bang nagpakita ng pag-aalala sa

Hindi
iyong paggamit ng mga nabanggit mong psychoactive substances?
(una, ikalawang droga, atbp)

a. Produktong tabako (sigarilyo, nganga, tabako, atbp) 0 6 3

b. Inuming nakakalasing (beer, alak, atbp) 0 6 3
c. Cannabis (marijuana, damo, halaman, five fingers, 0 6 3
omads, joint, roach, chongkee, maryjane, MJ, jutes, ganja, atbp)
d. Cocaine (coke, crack, rocks, ice, koka atbp) 0 6 3
e. Amphetamine type stimulants (speed, diet pills, ecstasy, Bangkok 0 6 3
pills, X, love drug, hug drug, happy pills, MDA, XTC, eckie,
lovedoves, adam or eden tablet, yuppy drug, atbp)
f. Sinisinghot (nitrous, rugby, glue, petrol, paint thinner, atbp) 0 6 3
g. Pampakalma o Pampatulog (Valium, Pinoy X, Dormikum, 0 6 3
Serepax, Rohypnol, atbp)
h. Hallucinogens (LSD, Shrooms, magic shrooms, kabute, Ketamine, 0 6 3
atbp)
i. Opioids (Nubain, Heroin, Morphine, Methadone, Codeine, atbp) 0 6 3
j. Kung may iba pa, pakibanggit: 0 6 3

Tanong 7 (T7)

tatlong buwan
tatlong buwan
Oo, pero hindi
sa nakaraang
nakaraang
kailanman

Oo, sa
Hindi
Nasubukan mo na bang pigilan, bawasan, o tigilan ang paggamit ng
mga nabanggit mong psychoactive substances, ngunit nabigo ka?

a. Produktong tabako (sigarilyo, nganga, tabako, atbp) 0 6 3

b. Inuming nakakalasing (beer, alak, atbp) 0 6 3
c. Cannabis (marijuana, damo, halaman, five fingers, 0 6 3
omads, joint, roach, chongkee, maryjane, MJ, jutes, ganja, atbp)
d. Cocaine (coke, crack, rocks, ice, koka atbp) 0 6 3
e. Amphetamine type stimulants (speed, diet pills, ecstasy, Bangkok 0 6 3
pills, X, love drug, hug drug, happy pills, MDA, XTC, eckie,
lovedoves, adam or eden tablet, yuppy drug, atbp)
f. Sinisinghot (nitrous, rugby, glue, petrol, paint thinner, atbp) 0 6 3
g. Pampakalma o Pampatulog (Valium, Pinoy X, Dormikum, 0 6 3
Serepax, Rohypnol, atbp)
h. Hallucinogens (LSD, Shrooms, magic shrooms, kabute, Ketamine, 0 6 3
atbp)
i. Opioids (Nubain, Heroin, Morphine, Methadone, Codeine, atbp) 0 6 3
j. Kung may iba pa, pakibanggit: 0 6 3

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 MAHALAGANG PAALALA:

Kailangan tanungin ang mga pasyenteng nagtuturok ng droga sa loob ng nakaraang tatlong buwan

tungkol sa pattern ng kanilang pagtuturok para malaman ang kanilang risk level at ang pinakamahusay na

paraan ng paggagamot

Pattern ng pagtuturok Gabay para sa interbensyon

(intervention)

Minsan sa isang linggo o Brief intervention gamitin pa rin ang risk

associated with injecting card
Mas kaunti sa tatlong magkakasunod na araw

Mahigit sa isang beses kada linggo o Karagdagang pagsusuri at

Tatlong araw o higit pa na magkakasunod mas masinsinang gamutan

Paano kalkulahin ang specific substance involvement score:

Kunin ang kabuuang score mula sa T2 hanggang T7 para sa bawat isang psychoactive substance
(mula a hanggang j). Huwag isama ang alin mang resulta mula sa T1 at T8 sa score na ito.
Halimbawa, ang puntos para sa cannabis ay maikakalkula gamit ang: T2c + T3c + T4c + T5c + T6c +
T7c

Tandaan na ang T5, para sa tabako ay hindi naka-code. Ito ay maikakalkula gamit
ang: T2a + T3a + T4a + T6a + T7a

Ang uri ng interbensyon ay matutukoy sa pamamagitan ng specific substance involvement score ng

kliyente.

Itala ang specific Walang Brief Masinsinang

substance interbensyon intervention gamutan
involvement
score
a. Produktong tabako (sigarilyo, 0-3 4-26 27+
nganga, tabako, atbp)
b. Inuming nakakalasing (beer, 0-10 11-26 27+
alak, atbp)
c. Cannabis (marijuana, damo, 0-3 4-26 27+
halaman, five fingers, omads,
joint, roach, chongkee,
maryjane, MJ, jutes, ganja,
atbp)
d. Cocaine (coke, crack, 0-3 4-26 27+
rocks, ice, koka atbp)

26 | P a g e
 Itala ang specific Walang Brief Masinsinang
substance interbensyon intervention gamutan
I. Amphetamine type stimulants involvement 0-3 4-26 27+
(speed, diet pills, ecstasy, score
Bangkok pills, X, love drug,
hug drug, happy pills,
MDA, XTC, eckie,
lovedoves, adam

or eden tablet, yuppy drug,

atbp)
II. Sinisinghot (nitrous, rugby, 0-3 4-26 27+
glue, petrol, paint thinner,
atbp)

III. Pampakalma o Pampatulog 0-3 4-26 27+

(Valium, Pinoy X,
Dormikum, Serepax,
Rohypnol, atbp)

IV. Hallucinogens (LSD, 0-3 4-26 27+

Shrooms, magic shrooms,
kabute, Ketamine, atbp)

V. Opioids (Nubain, Heroin, 0-3 4-26 27+

Morphine, Methadone,
Codeine, atbp)

VI. Kung may iba pa, 0-3 4-26 27+

pakibanggit:

Paalala: Ang masinsinang pagsusuri at mas malalim na gamutan ay maaring ibigay ng mga health
professional sa iyong primary care setting o ng isang ispesyalista sa paggamot ng droga o alkohol, kung
meron man

27 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

Mental Health Problems – Self Reported Questionnaire (SRQ)

Mental Health Problems – Self Reported Questionnaire (SRQ)

Oras sa pagsagot sa interbyu: __________________________ - ID ng pasyente: __________________

Kung naaangkop sa iyo ang tanong at naranasan mo sa loob ng nakaraang 30 araw ang problemang
inilarawan, isagot ang “Oo”.

0. I Tanong Oo Hindi
1. tMadalas ka bang nakakaranas ng sakit ng ulo? Oo (1) Hindi (0)
eNawawalan ka ba ng ganang kumain?
2. Oo (1) Hindi (0)
m
3. Nahihirapan ka bang matulog nang maayos? Oo (1) Hindi (0)
4. Nanginginig ba ang iyong mga kamay? Oo (1) Hindi (0)
5. Madali ka bang matakot? Oo (1) Hindi (0)
6. Nakakaramdam ka ba ng nerbyos, tensyon o pag-aalala? Oo (1) Hindi (0)
7. Mahirap ba ang panunaw mo? Oo (1) Hindi (0)
8. Nahihirapan ka bang mag-isip nang malinaw o magpokus? Oo (1) Hindi (0)
9. Nakakaramdam ka ba ng pagkalungkot? Oo (1) Hindi (0)
10. Napapaiyak ka ba ng mas madalas kaysa dati? Oo (1) Hindi (0)
11. Nahihirapan ka bang mag-enjoy sa iyong mga pang-araw-araw Oo (1) Hindi (0)
na gawain?
12. Nahihirapan ka bang gumawa ng desisyon? Oo (1) Hindi (0)
13. Naapektuhan/ nagdurusa ba ang iyong pang-araw-araw na trabaho? Oo (1) Hindi (0)
14. Hindi ka na ba nakakagawa ng kabuluhan sa iyong buhay? Oo (1) Hindi (0)
15. Nawalan ka ba ng interes sa mga bagay-bagay? Oo (1) Hindi (0)
16. Pakiramdam mo ba na wala kang kwentang tao? Oo (1) Hindi (0)
17. Sumagi na ba sa isip mo ang pagpapakamatay? Oo (1) Hindi (0)
18. Pakiramdam mo bang palagi kang pagod? Oo (1) Hindi (0)
19. Nakaramdam ka ba ng hindi pagbuti ng iyong tiyan? Oo (1) Hindi (0)
20. Madali ka bang mapagod? Oo (1) Hindi (0)
Kabuuan:

Oras na natapos ang panayam/ interbyu: ____________

Translated into Filipino from The Self-Reporting Questionnaire, Geneva, World Health Organization, 1994. WHO is
not responsible for the content or accuracy of this translation. In the event of any inconsistency between the English
and the translation, the original shall be the binding and authentic version.

28 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

TAB C

TREATMENT
(MIOP and UNODC Training Certificate
& Schedule of Activities)

29 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

MIOP-CBT TRAINING CERTIFICATE

ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

30 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

MIOP-CBT TRAINING CERTIFICATE

ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

-+

31 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

MIOP-CBT TRAINING CERTIFICATE

ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

32 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

MIOP-CBT TRAINING CERTIFICATE

ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

33 | P a g e
34 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

MIOP-CBT TRAINING CERTIFICATE

ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

35 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

GINHAWA and KKDK TRAINING

CERTIFICATE
ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

36 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

GINHAWA and KKDK TRAINING

CERTIFICATE
ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

37 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

GINHAWA and KKDK TRAINING

CERTIFICATE
ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

38 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

GINHAWA and KKDK TRAINING

CERTIFICATE
ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

39 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

GINHAWA and KKDK TRAINING

CERTIFICATE
ANTI-DRUG ABUSE COUNCIL (ADAC) FOCAL PERSON

40 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

ACTIVITY DESIGN

I. Activity Title

TARA NA (Tabangan Atong Refromists Aron Naa’y Asenso) Davao City

Community Based Rehabilitation and Aftercare Program

Name of Barangay: WANGAN

II. Rationale

Pursuant to RA 9156 otherwise known as the Comprehensive Dangerous Drugs Act

of 2002, Article VII, Section 51, local government units shall appropriate a
substantial portion of their respective annual budgets to assist in or enhance the
enforcement of this Act giving priority to preventive or educational programs and
the rehabilitation or treatment of drug dependents.

Likewise, as provided by the Department of Health Administrative Order No. 0018

Series of 2017, Section VI B, the Anti-Drug Abuse Council shall lead in the formulation
of the plan of action for the community-based treatment and support services. The
TARA NA CBRAP framework shall be followed and implemented in the Barangays by
virtue of CADAC Resolution No. 2, Series of 2017.

This activity is designed to optimize the budget of the BADAC’s though a service
mix or prescribed content with one day per month activity for the TARA NA
CBRAP in the Barangays.

III. Objectives

This activity aims to enhance proficiency of the barangay residents in the

implementation of TARA NA CBRAP.

Specifically, this activity aims to:

1. To enumerate the distinctive characteristics of TARA NA CBRAP

Management Approach;
2. To understand the science of addiction;
3. To enumerate the methods of treatment and management of drug
addiction or substance use disorder;
4. To list the co-occurring disorders;
41 | P a g e
 5. identify/list the recovery capital of the client;
6. To learn early recovery skills and relapse prevention skills;
7. To enumerate the 13 sessions of the better than wine module for
spirituality;
8. To identify ways for therapeutic recreational activities; and
9. To identify the different maladaptive coping response and healthy coping
style.

IV. Expected Output

At the end of the year, 600 residents from the Barangay shall be proficient in the
implementation of the TARA NA CBRAP.

V. Methodology

1. Lecture
2. Open Forum
3. Pre-test/posttest

VI. Operational Details

Expected Number of Participants: 50

Category of Participants

1. Reformists
2. Reformists’ Families
3. Youth
4. ADAC
5. BPOC
6. Service providers

No. of Participants: 50
Schedule: Once a Month for 12 Months
Meals: Morning Snacks, Afternoon Snack, Lunch

VII. Budgetary Requirements

Nature of Expenses No. of Pax Unit Cost Frequency/Year Total Cost

1. Meals 50 ₱500 12 ₱300,000

2. Honoraria 5 ₱1000 12 ₱6,000
3. Reproduction ₱6000 ₱6,000
Total ₱366,000

42 | P a g e
 I. Source of Fund
Barangay Anti-Drug Abuse Council

II. Schedule of Activities

Time Topic Resource Person

8:00 Registration Barangay staff
8:30 Preliminaries
Pre-test
9:00 Community-Based Recovery Support System: DepEd/CADAC
TARA NA CBRAP/Management Approach

10:00 Schema Therapy: Maladaptive Coping DepEd/CADAC

Response /Coping Styles
Cognitive Restructuring
11:00 Science of Addiction: Treatment and DepEd/CADAC
Management/ Co-Occurring Disorders/
Treatment and Management
LUNCH BREAK
1:00 Recovery Capital DepEd/CADAC
2:00 Early Recovery Skills DepEd/CADAC
3:00 Relapse Prevention Skills DepEd/CADAC
4:00 Management of Learning /Posttest DepEd/CADAC

Submitted by:

HON. DANILO M. ABABON

Punong Barangay

Recommended for Approval By:

JAFFAR U. MAROHOMSALIC
CADAC Action Officer

43 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

ACTIVITY DESIGN

I. TITLE: Psychoeducation: Early Recovery Skills and Relapse

Prevention for TARA NA CBRAP Clients and Service Providers

II. RATIONALE:
The TARA NA – CBRAP also known as Tabangan Atong Reformists Aron
Naay Asenso: A Community-Based Rehabilitation and Aftercare
Program is a program dedicated to providing necessary services for the
recovery and aftercare of the reformists in Davao City.

One of the objectives of the program is to reintegrate reformists back

to their respective communities as responsible, useful and productive
individuals. They must be provided with the necessary services for the
recovery of the social well-being of the reformists in order for them to
be reintegrated to their respective communities.

Psychoeducation is an important component in the treatment for the

improvement of his knowledge specifically learning early recovery and
relapse prevention skills.

III. OBJECTIVES:

44 | P a g e
 1. To understand the science of addiction
2. To enumerate the different levels of drug dependency and
appropriate treatment and management
3. To be able to learn how to facilitate /conduct health education
on early recovery and relapse prevention skills
4. To enumerate the nine distinct characteristics of case
management approach

IV. Methodology

 Lecture
 Workshop
 Pretest/Post
test

IV. Operational Details

Expected Number of Participants: 50

Category of Participants

7. Reformists
8. Reformists’ Families
9. Youth
10. ADAC
11. BPOC
12. Service providers

No. of Participants: 50
Schedule: Once a Month for 12 Months

45 | P a g e
 Meals: Morning Snacks, Afternoon Snack, Lunch
V. Budgetary Requirements
Nature of No. of Pax Unit Cost Frequency/Year Total Cost
Expenses
4. Meals 50 ₱500 12 ₱300,000
5. Honoraria 5 ₱1000 12 ₱6,000
6. Reproduction ₱6000 ₱6,000
Total ₱366,000

46 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

SCHEDULE OF COMMUNITY BASED DRUG REHABILITATION PROGRAM

SESSION DATE TIME TOPIC CONTENT FACILITATORS
ORIENTATION 8:00 AM - INTERVIEW RULES AND REGULATIONS
AND DRUG 12:00 INTRODUCTION RELATED TO THE CONDUCT OF LGOO/RHU/PNP/DSWD
TESTING NOON THE CBRP/MIOP
EARLY RECOVERY SKILLS
SESSION 1 1:00-2:30 STOP THE CYCLE ERS INTRODUCTION (INDIVIDUAL
PM TEXT CARD)
JEFF ANTHONYVAZQUEZ
UNDERSTANDING TRIGGERS AND
THOUGHT STOPPING TECHNIQUES
SESSION 2 8:30-9:30 COMMON FINDING COPING TECHNIQUES
AM CHALLENGES IN
EARLY RECOVERY
SESSION 3 9:40-10:40 THINKING, UNDERSTANDING CONNECTIONS JEFF ANTHONYVAZQUEZ
AM FEELING, DOING AMONG THOUGHTS, EMOTIONS
AND BEHAVIOR
SESSION 4 8:30- 9:45 STEP SAYINGS JEFF ANTHONYVAZQUEZ
AM
SESSION 5 10:00 - SPIRITUAL PTR. WENDELL L. TOLIBAS
11:30 AM COUNSELLING
SESSION 6 9:00-10:00 EXTERNAL UNDERSTANDING AND EDWARD IROY
AM TRIGGERS IDENTIFYING EXTERNAL
TRIGGERS

47 | P a g e
SESSION 7 10:15 - INTERNAL UNDERSTANDING AND EDWARD IROY
11:30 AM TRIGGERS IDENTIFYING INTERNAL
TRIGGERS

SESSION 8 9:00-10:00 12 STEP

AM INTRODUCTION
SESSION 9 10:15-11:30 BODY CHEMISTRY UNDERSTANDING THE RECOVERY JEFF ANTHONY VAZQUEZ
IN RECOVERY PROCESS

RELAPSE PREVENTION
RP 1 8:30-9:30 ALCOHOL UNDERSTANDING HOW ALCOHOL
AM JEOPARDIZED RECOVERY
JOSEPH QUEREQUENCIA

RP 2 9:45-10:45 BOREDOM UNDERSTANDING BOREDOM AND

AM ITS RISK TO RECOVERY
RP 3 10:45-12:00 AVOIDING UNDERSTANDING THE PROCESS
noon RELAPSE DRIFT OF RELAPSE

RP 4 8:30-9:40 WORK AND UNDERSTANDING HOW WORK

AM RECOVERY LIFE AFFECTS RECOVERY
RP 5 10:00-11:00 GUILT AND ADDRESSING FEELINGS OF GUILT
AM SHAME AND SHAME JEFF ANTHONY VAZQUEZ
RP 6 11:00- STAYING BUSY UNDERSTANDING THE
12:00 IMPORTANCE OF SCHEDULING
NOON AND HOW FREE TIME CAN ACT AS
A TRIGGER

48 | P a g e
RP 7 8:30-9:30 MOTIVATION FOR UNDERSTANDING HOW
AM RECOVERY MOTIVATION FOR RECOVERY
AFFECT PROGRESS
RP 8 9:45- 10: 45 TRUTHFULNESS UNDERSTANDING THE PTR. WENDELL L. TOLIBAS
AM RELATIONSHIP OF TRUTHFULNESS
AND SUBSTANCE DEPENDENCE

RP 9 11:00- TOTAL CONNECTION BETWEEN ALCOHOL

12:00 ABSTINENCE AND OTHER SUBSTANCE USE AND
NOON RELAPSE TO STIMULANTS

RP 10 8:30-9:30 SEX AND DISTINGUISHING INTIMATE AND

AM RECOVERY IMPULSIVE SEX

RP 11 9:45-11:00 ANTICIPATING UNDERSTANDING AND

AM AND PREVENTING RECOGNIZING WARNING SIGNS OF
RELAPSE RELAPSE JOSEPH QUEREQUENCIA

RP 12 11:00 - TRUST THE ROLE OF TRUST IN THE

12:00 RECOVERY
NOON IMPORTANCE OF SELF-ESTEEM TO
RECOVERY
RP 13 8:30-9:45 BE SMART, NOT UNDERSTANDING THAT
AM STRONG RECOVERY IS A TEST OF WILL
RP 14 10:00-11:00 DEFINING ROLE OF SPIRITUAL BELIEFS TO PTR.WENDELL. TOLIBAS
AM SPIRITUALITY RECOVERY

RP 15 8:30-9:45 MANAGING LIFE, HOW SUBSTANCE ABUSE

AM MANAGING ENCOURAGES IRRESPONSIBILITY JEFF ANTHONY VAZQUEZ
MONEY

49 | P a g e
 RP 16 10:00-11:00 RELAPSE UNDERSTANDING RELAPSE
AM JUSTIFICATION 1 JUSTIFICATION

SECOND DRUG TEST

SESSION 3 8:30-9:30 CONTINUING
AM TREATMENT
PLANNING
RP 17 9:45-11:00 TAKING CARE OF IMPORTANCE OF SELF-ESTEEM TO
AM YOURSELF RECOVERY
JOSEPH QUEREQUENCIA
RP 18 11:00-12:00 ILLNESS ILLNESS AS RELAPSE TRIGGER
AM

RP19 1:30 – 3:00 RECOGNIZING STRESS AND ITS EFFECTS TO

PM STRESS RECOVERY
RP 20 3:00 – 4:30 RELAPSE HOW RELAPSE JUSTIFICATION PTR. WENDELL L. TOLIBAS
PM JUSTIFICATION 2 LEADS TO RELAPSE TOLIBASL.TOLIBAS

RP 21 9:00-10:00 MANAGING ANGER AS AN EMOTIONAL

AM ANGER TRIGGER JEFF ANTHONY VAZQUEZ

RP 22 10:15- REDUCING COPING WITH STRESS

11:30 STRESS
RP 23 10:00-11:00 ACCEPTANCE ACCEPTING SUBSTANCE USE
AM DISORDER EDWARD IROY
RP 24 11:00-12:00 MAKING NEW ROLE OF FRIENDS IN RECOVERY
AM FRIENDS
RP 25 8:30-9:40 REPAIRING THE NEED TO REPAIR
AM RELATIONSHIP RELATIONSHIP

50 | P a g e
 RP 26 10:00- SERENITY SPIRITUALITY ENHANCEMENT PTR. WENDELL L. TOLIBAS
11:15 PRAYER
RP 27 AM
8:00-9:00 COMPULSIVE ELIMINATING COMPULSIVE
AM BEHAVIORS BEHAVIORS
RP 28 9:00-10:00 COPING WITH EMOTIONAL PATTERNS IN
AM FEELINGS AND RECOVERY
DEPRESSION
RP 29 9:00-10:00 LOOKING BENEFITS OF PLANNING
AM FORWARD; REWARDS AND DOWNTIME
MANAGING PTR. WENDELL L. TOLIBAS
DOWNTIME
RP 30 ONE DAY AT THE PAST DOES NOT DEFINE THE
TIME FUTURE
THIRD DRUG-TESTING EDWARD IROY

GRADUATION CBRP TEAM

Prepared by: Noted by

KAGAWAD RICARDO E. MONDIGO DR. JOJIT MARBAS

BADAC OFFICER District Health Officer

51 | P a g e
 BARANGAY ANTI-DRUG ABUSE COUNCIL

STRUCTURED WEEKLY/ MONTHLY ACTIVITIES FOR PWUDS

MONTH OF DECEMBER 2023

WEEK Mon. Tues. Wed. Thu. Fri. Sat. Sun.
1st Screening/ Assist Zumba MIOP
Week S1

2nd MIOP S2 Comm. MIOP

Week Service S3

3rd Zumba MIOP MIOP

Week S4 S5

4th MIOP MIOP

Week S14 S6

MONTH OF JANUARY 2024

WEEK Mon. Tues. Wed. Thu. Fri. Sat. Sun.

1st MIOP Zumba MIOP

Week S16 S17

52 | P a g e
 2nd MIOP MIOP MIOP
Week S18 S20 S17

3rd Comm. MIOP Zumba

Week Service S27

4th MIOP MIOP Comm.

Week S30 S31 Service

53 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

TAB D

REFERRALS
(HIGH RISK FOR DRUG
DEPENDENCE & WITH CO-
MORBIDITIES)

54 | P a g e
55 | P a g e
 Republic of the Philippines
City of Davao
OFFICE OF THE PUNONG BARANGAY
Barangay Wangan, Calinan District

BARANGAY ANTI-DRUG ABUSE COUNCIL

PERSON WHO USES DRUGS (PWUDS) REFERRAL FORM

Referred by: _______________________________________________________________

Barangay: ________________________________________________________________
First Name: ______________________________________________________________
Last Name: _______________________________________________________________
Date of Birth: ________________________________ Gender: _____________________
Address: _______________________________________________________________
Contact Number: __________________________________________________________

REFERRING CBDRP FOCAL INFORMATION:

Name: ________________________________________________________________
Position: ______________________________________ Contact Number: _____________

Screening/Findings of Patient:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

REFERRING PHYSICIAN INFORMATION:

Name: ____________________________________________________________________
Position: ______________________________________ Contact Number: _____________
Screening/Findings of Patient:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

56 | P a g e