Supervised Visitation Intake Form Supervised Visitation For DRC private visitation program About YouYour Name(Required) First Last I am the:(Required)FatherMotherFamily MemberGuardianYour Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Phone(Required)Your Email Address(Required) Email Address Confirm Email Address Preferred Method of ContactEmailPhoneEmployer and Job: (If unemployed, indicate unemployed)(Required) Availability for Visits:(Required) In which language do the child(ren) speak to you?(Required) Annual Income: (Needed for calculation of sliding fee)(Required)Under $15,000$15,000 – $30,000$30,000 – $40,000$40,000 – $55,000$55,000 – $65,000Over $65,000How often, and for how many hours at a time, would you like to set up visits?(Required) Name of Custodial Party/Other Parent(Required) First Last Phone of Custodial Party/Other Parent(Required)Do you have contact with the custodial party?(Required) Indicate the status of your relationship with the other parent:(Required) Divorced Separated Never Married Married No relationship Date of Separation/Divorce (if relevant) Estimate how many times you've been to court concerning visitation disagreements? Court/Judge Information (if none, write n/a)(Required) Is there an Order of Protection preventing you and the other party from having direct contact with each other?(Required) Active and Ongoing Lapsed or Expired None Have the police ever been called for an altercation between the parents?(Required) Yes No Other Is there a history of abuse by one parent toward another?(Required) Yes No Other Please enter the name / gender / age of the child(ren)(Required)Do any of the child(ren) have special needs or medical needs? If yes, indicate which child and what the needs are.(Required) Do any of the child(ren) have allergies or dietary restrictions? If yes, indicate which child and what the restrictions are.(Required) What is your understanding of the reason why you were referred to supervised visitation?(Required)The decision for visitation was made by or with assistance from:(Required) Counselor or Mediator You and the other parent Attorney Court / Judge Please describe the current visitation arrangements.(Required) Do you have any concerns, or is there anything else you would like us to know?(Required)CAPTCHA
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