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Supervision Form



SUPERVISED VISITATION PROGRAM
CLIENT INTAKE FORM

Contact Date_____________

Fee ____$20
____$25(Out-of-County)
Date Paid______________ Court
Order_____ CPS_____ Income & Expense Statement_______
Restraining Order ____Yes ____No Hourly Rate ____________

CUSTODIAL PARTY _________________________________________________
STREET ADDRESS __________________________________________________
________________________________________________________________
CITY STATE ZIP
PHONE HOME __________________ WORK __________________________

ATTORNEY_______________________________ PHONE__________________

#############
SUPERVISED PARTY _______________________________________________

STREET ADDRESS___________________________________________________

________________________________________________________________
CITY STATE ZIP
PHONE HOME ________________
WORK_____________________________
ATTORNEY_______________________________
PHONE__________________

Briefly describe reason supervision required.

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

How many children?
Boy(s)_____
Girl(s)_____
Name(s) & Age

1. _________________________
Age _____

2. _________________________
Age _____

3. _________________________
Age _____

4. _________________________
Age _____

5. _________________________
Age _____

Page 2

Date Supervision can begin ____________________________________

City/County of Supervision_____________________________________

Public meeting place ______
or Private residence ______

Who can attend ______________________________________________

Hours________________________________________________________

Days: M_____T_____W_____Th_____F_____Sat_____Sun_____

Next Court Review Date_______________________________________

Anticipated end of Supervision:
Date _________
Unknown _____

Is the Visiting parent currently on:

_____Probation/Parole Probation Officer Name: ________________

_____Prescription Medication Name: ___________________________

Questions regarding Supervisors:

Language other than English___________________

Experience with special needs_________________

Both parties are responsible for screening the Supervisor to determine if he or
she is appropriate for their needs.

_______ Date advised mother

_______ Date advised father

*****************************************************************For our
records:

Supervisor providing services: __________________________________

Starting date: _____________ Visits scheduled for (include time)
M_____ T______ W______ T______ F_____ Sat_____ Sun_____

Ending date: _______________
or Termination date: _______________

Availability of Supervisor

Days ______
evening(s) ______

M _____ T_____ W_____ Th_____ F_____ Sat_____ Sun_____