Supervised Visitation/Exchange Intake Form
This form should be completed and submitted in advance of your scheduled intake interview. In the required section, if you do not know the correct answer please put Do Not Know, if the question does not apply to your situation, please put N/A. The purpose of this form is to help the Monitor to understand the dynamics and background of your situation. Please be accurate, truthful and complete in your answer. This information is for the monitor's use only and will not be shared with the other party. Thank you for your cooperation.
Email address *
Name *
First and last name
Email *
Home Physical Address *
Mailing Address *
Phone number *
Your Date of Birth *
Your Age: *
Emergency Contact Person *
Place of Employment *
Position *
Work Schedule *
Driver's License and Car Information - The monitor will need a copy or photo of your driver's license, proof of car insurance, and car registration. You must provide this information for all vehicles the monitor and child are passengers. *
Visiting Person's Name *
Visiting Person's Cell Phone Number *
Your relationship to minor child *
Re: Interest of Minor child(en) - Please list each child full name, age, date of birth, gender *
Do you have a signed Court Order from the Judge? *
What is the Court Order DR#? Please provide a copy of the signed court order to the monitor. *
If you do not have a copy of the Court Order describe the requirements of the Court Order *
Who is responsible for the fees? *
If there are no specific guidelines in the Court order concerning payments are you willing to follow the policy and procedure of the monitor? *
If you have an attorney, please provide contact information below: Name, Telephone Number, Address and Email address. *
What is the schedule of visitation recommended by the Court? *
You and the child's other parent relationship *
Why are supervised visits or exchanges necessary? *
Substance Abuse - Specify
Mental Illness - Specify
Kidnapping (Date of incident or threat)
Domestic Violence (Date of incident)
Has Department of Social Services or a CPS (Child Protective Services) agency ever been involved with the children/family? *
Provide details of CPS involvement. When? What Reason?
Have you ever been ordered or voluntarily taken parenting classes or co-parenting classes
Is there anything in particular you would like to find out about or related to supervised visits and/or parenting?
Have you ever seen a therapist or counselor as it relates to this case
If so, when and for what reason
Do you have a physical or chronic condition that may interfere with visitation? If so what? *
When was the last visit or exchange with the child(en) and was it supervised? *
What problems, if any, do you expect from the other party with visits or exchanges? *
What do you hope the outcome from this experience will be? *
What level of interaction do you expect of the Monitor during the visits? Please note that the Monitor must always be in control of the visit and reserves the right to end a visit at their discretion. *
I understand that visits normally take place at public locations. If the visiting parent elect to visit at locations that requires additional cost and or meals over $10 it is the responsibility of the visiting parent to pay for the monitor's expenses. If the visiting parent do not agree to cover the expenses and do not agree to select other options, the monitor reserve the right to cancel the visit and all fees are non refundable and non transferable. Do you agree to these terms? *
Have you reviewed the Supervised Visitation Agreement, Policy and Guidelines. Do you agree to the terms and conditions of these documents? *
Questions, concerns or comments
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