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__________________
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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_____