The WellStar Visitation Referral

Supportive Supervised Visitation

Referral Form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring County
Case Name

First NameLast Name
Visiting Parent Information

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Visiting Parent Information

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Additional Visiting Parent Information

Placement Information
Placement:

First NameLast Name
Placement Type
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Additional/ Multiple Placement Information

Referring Person's Contact Information
Referring Individual

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com

Attorney Information
Please List the name of the Mother's Attorney
Please List the name of the SAG
Please List the name of the GAL
Please List the name of the Father's Attorney

Children's Information

Visiting Child(ren)

Rows	Child(ren) Name	Gender	DOB	Medical Concerns / Allergies
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information

Removal Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who were the child(ren) removed from?

Children's Medical/Mental Illness
Does any of the child(ren) have any medical or mental health issues that we need to be aware of during the visit?
Are their any medications that the child(ren) need to take that the parents need to administer during the visit?
*Please note The Children's Haven does not administer medication unless it has been approved by DFCS and agreed by Visitation Director.

If administering medication requires training, the parent needs to be trained.

Safety Planning
Why is DFCS involved with this family?
What has DFCS identified as a safety concern/ restrictions that The Children's Haven need to be aware of during the visits?
Name of the the individuals restricted from visiting?

Court Information
Has the court found the child(ren) dependent?
When is the next court date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Most Recent Court Order

Browse Files

Cancelof
Other Pertinent Information

Browse Files

Cancelof
Provide any case restriction outline in the court order or visitation plan.

Transportation Services
Has Transportation been set up?
Please list the name of the contact information for the individual or provider(s).
Name

First NameLast Name
Phone Number

Area CodePhone Number
Additional transportation providers:
Should be Empty: