2HomeKids Supervised Visitation and Exchange Intake Form

{yourName39} | {date} | {areYou} | {whatServices174}
2HOME KIDS SUPERVISED VISITATION AND EXCHANGE FORM

The purpose of this form is to provide information that 2HomeKids uses for statistical purposes when applying for grant funding. Your information will not be released and is kept private.

GRANTS help HH maintain lower rates and provide resources for our facility.

Note: This form consists of a number of pages. Please take your time completing the form. If you want to take a break, simply click Save at the bottom of the page to save your work and return to complete the form later.
What Services Are You Requesting?
If Both, please provide case numbers for ALL cases.
Are You... (check one)
Date

MonthDayYear
Your Name

PrefixFirst NameMiddle NameLast Name
Other Party's Name
Other Party's Email
Other Party's Phone Number

Preferred Visitation Times (Hannah's House hours: M-F, 8am-8pm | SAT-SUN, 9am-6pm)

Rows	Times
Mon
Tue
Wed
Thu
Fri
Sat
Sun

Day(s) and/or Time(s) That You Absolutely Cannot Bring Children (Due to Work Schedule or Mandated Courses Only)

Rows	Times
Mon
Tue
Wed
Thu
Fri
Sat
Sun

FOR INTERNAL USE ONLY

COMPLETED STEPS: Phone Screening ⬜ Required Docs ⬜ Intake ⬜ ID ⬜

ORIENTATION FEE: $150 (Both) ⬜ $75 (Individual) ⬜ $100 (Private) ⬜ $30 (TP) ⬜

COMMENTS: _______________________________________________________________________

RELEASE OF INFORMATION: FCS ⬜ Attorney ⬜ Therapist ⬜ Evaluator ⬜ Other: ____________

RECEIVED DOCUMENTS: FCS Reports ⬜ Current Court Orders ⬜ Current RO ⬜
Proof of Income ⬜ Child Support ⬜

COMMENTS: ________________________________________________________________________

ATTORNEY CONTACT (if applicable): VP ⬜ RP ⬜ NONE ⬜

AUTHORIZED TP: ____________________________

SIGNED 2HK AGREEMENT: ⬜

Rows	Name	Phone
Contact 1
Contact 2

Rows	Name	Phone

{yourName39} | {date} | {relationshipTo} | {whatService}
For RESIDENTIAL PARTY ONLY: Policy on Information Sharing for Visitation

2HomeKids has observed that, in some cases, an RP may become upset in front of the child/ren if something occurs on a visit that the RP is not expecting. As a preventative approach to minimize stress for the child/ren, we ask each RP to complete the Residential Party Information-Sharing/Special Needs Questionnaire.

The RP information provided on this form is used as a guide and does not represent rules of the House unless otherwise specified. The information is used primarily to ensure the House and the other parent of the child/ren have the information necessary to provide appropriate care. Any item other than physician-documented health concerns may be over-ridden by House staff if it is in the best interest of a child in the context of their family visitation.

This form is available to all parties on the case at any time and may be changed by the Resident Parent upon request.
GUESTS: Please indicate your wishes regarding guests accompanying the visiting parent. If there are specific people/animals you think are always okay, list their names and relationship to the visiting parent in the space provided below.

Note: The House staff may limit guests during visitation if it is felt that the guests are interfering in any way with the Child/ren ability to interact with the visiting parent, or if the guests appear to be causing undue distress on the Child/ren or the visiting parent.
PG MOVIES: APPLIES TO SOLE LEGAL ONLY
COMMENTS:
MEAL TIMES
Breakfast
Lunch
Dinner
FOOD RESTRICTIONS (PHYSICIAN DOCUMENTATION MUST BE PROVIDED)
My child/ren is/are allergic to the following foods:
Child/ren's favorite foods for MEALS and/or SNACKS:
MEDICATIONS (PHYSICIAN DOCUMENTATION MUST BE PROVIDED)
My child takes the following medication(s) at the times indicated.
A copy of this form shall be provided to the Visiting Parent upon request.
Your Signature
Print Name
Date

MonthDayYear
Staff Signature
Staff Print Name
Date

MonthDayYear

{yourName39} | {date} | {relationshipTo} | {whatService}
CONSENT AND RELEASE FORM
I, (enter your name below)
Hereby authorize the release of information and records pertaining to my case between

2 HomeKids Staff
9455 Farnham Street, Suite 100
San DIego, CA 92123

And...
Other
Name (FCS Mediator, Attorney, Child's Attorney Evaluator, Child's Therapist, CPS, or Other)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
INFORMATION TO BE RELEASED

Other
This information may be released to comply with Court Orders in compliance with section 5.20 of the California Family Code. I acknowledge that this consent is voluntarily given. I hereby forever release and hold harmless the above parties for releasing information or records in reliance on such consent.

I understand my consent to release information or records are subject to revocation at any time, except to the extent that action has already been taken in reliance thereon, or if a release is not required by law. Unless revoked sooner, this authorization expires on (enter date below).
Authorization Expires on (date)

MonthDayYear
Signature
Date

MonthDayYear
Witness Signature
Date

MonthDayYear

{yourName39} | {date} | {relationshipTo} | {whatService}
NEW CLIENT ANGER INVENTORY
Number of True Responses
Signature
Print Name

{yourName39} | {date} | {relationshipTo} | {whatService}
INCOME VERIFICATION

I understand that the financially responsible party(s) must provide proof of income PRIOR to the first scheduled visit. If documentation is not provided, the fees for service will automatically be set at the highest co-pay rate; a later reduction in fees based on a delayed provision of Proof of Income is NOT retroactive.

Accepted Methods of Proof:
- Two (2) Months of Paystubs
- Six (6) Months of Bank Statements
- Three (3) years of Income Tax Filings
- Unemployment Letter/Documentation
- Disability Letter/Documentation
Signature
Date

MonthDayYear
Staff Signature
Date

MonthDayYear

{yourName39} | {date} | {relationshipTo} | {whatService}
2HOMEKIDS (HANNAH'S HOUSE) AGREEMENT
I, (enter name below)
Initial Here (use mouse or finger)
I Am the (check all that apply):
Initial Here

I understand each party is responsible to pay for their own orientation fees unless the Court Order specifies one (1) party is responsible for “All fees/100% of fees.”

Initial Here
I understand I am responsible to pay my own Early and/or Late fee.
Initial Here

I understand I am responsible to pay 100% of the fee for my own cancellation of a regularly scheduled visit, regardless of the amount of notice, unless I provide proper documentation. [Exception: Short notice cancellation for documented illness, change in work schedule, and/or automobile accident/breakdown]

Initial Here

I understand Supervised Visitation* is offered on a Sliding Fee Scale based on gross monthly income. Child Support (for the case/child(ren) at 2HKs) is the only expense that reduces the gross monthly income. The VP is responsible to pay the full fees unless the Court Order specifies the cost are to be split between both parties, or if it is indicated the CP is responsible for “all fees/ 100% of fees.” The financially responsible party must provide proof of income prior to the beginning of services.

*100% of contact between NCP and the Child(ren) is supervised.

Initial Here

I understand one (1) full Supervised Exchange (i.e., a supervised transfer of the child(ren) from one parent to the other and back again) costs $40.00: $20.00 for a pick-up and $20.00 for a drop-off. A party is responsible to pay the full fee unless the Court Order specifies the costs are to be split between two parties.

Initial Here

I understand my fees are set based on the date I provide Proof of Income and a new rate (whether higher or lower) is not retroactive.

Initial Here

I understand I may be charged additional Administrative Fees of $25-$50 per occurrence, if I require excessive administration time and services which include but are not limited to excessive emails, phone calls, unscheduled in-person conversations in a day.

Initial Here

I understand a Subpoena response is charged $75/hr for records preparation; $100/hr for a Supervisor; $125/hr for a Senior Supervisor; $150/hr for Custodian of Records time; and $200/hr for the Executive Director’s time. A two (2) hour payment is required in advance of any subpoena or court appearance by 2HK’s Staff; i.e. $200 or $250 must be paid in advance of the appearance. Additional time must be paid immediately following appearance.

Initial Here

I understand I am required to update 2HK with any new court orders after each court appearance. I understand if my case no longer needs 2HK’s services, 2HK will verify with the other party in order to close the case.

Client Signature
Date

MonthDayYear
Staff Signature
Date

MonthDayYear

{yourName39} | {date} | {relationshipTo} | {whatService}
2HOMEKIDS INFORMED CONSENT FORM

At Hannah’s House we consider ourselves a wrap around service meaning we want to cover every area a family could need to harmonize. We have 3 programs and over 40 services from which we believe all of our families can benefit.

2HomeKids offers supervised visits and safe exchanges. Transitions Family Program is our clinical therapy program offering therapeutic services, psycho-educational classes and free support groups amongst other things. Human Animal Bond Program uses animals to bring parents and children together, Our Animal Staff draw family members closer together in these amazing shared experiences that open communication and facilitate deeper engagement with each other.

By signing this paper you authorize Hannah’s House to distribute your information to all services under our organization so they can review case information in order to determine and offer all the services we can to best assist you and your family.
I, (enter your name)
, authorize Hannah’s House to release my case information to all 3 programs (2HomeKids, Transitions Family Program, Human Animal Bond Program)
Date

MonthDayYear
Date
Email
example@example.com
Signature (use mouse cursor or finger)
Should be Empty:

Rows	Name	Age	Gender	Birth Date
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8

2HOME KIDS SUPERVISED VISITATION AND EXCHANGE FORM

FOR INTERNAL USE ONLY

For RESIDENTIAL PARTY ONLY: Policy on Information Sharing for Visitation

MEAL TIMES

FOOD RESTRICTIONS (PHYSICIAN DOCUMENTATION MUST BE PROVIDED)

MEDICATIONS (PHYSICIAN DOCUMENTATION MUST BE PROVIDED)

CONSENT AND RELEASE FORM

NEW CLIENT ANGER INVENTORY

INCOME VERIFICATION

2HOMEKIDS (HANNAH'S HOUSE) AGREEMENT

2HOMEKIDS INFORMED CONSENT FORM