Bright House Visitation Referral

Supervised Visitation Referral

705 Harmon Street, Savannah, GA 31401 | 912-346-2104 | brightsideadvocacy.org
Thank you for choosing The Bright House to provide safe and supervised visitation to the families in our community. The Bright House will ensure that visitations take place in a controlled environment to maximize developmentally appropriate interactions in a home-like setting for our families.

Please complete this referral in its entirety to enable us to create individualized safety plans and provide tailored services. Once we are in receipt of your referral, we will contact the parent/visitor within 3 business days to schedule an intake. After completion of the intake, the Bright House manager will notify the parties of the visitation schedule.

If you or another party to the case would like to visit the family during their visitation, then please contact the Bright House manager one week prior to your desired visitation.

Once services commence, the referring individual will be sent monthly updates on the progress of visitations.

Thank you,

Ja'Nae Brown
Bright House Manager
1. Date

MonthDayYear
Date
2. Referral County*
3. Referral Source*

DFCSJuvenile CourtPrivate AttorneySuperior CourtCASA (please include name of coordinator)Other
Referring Individual, Phone Number, & Email
4. Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
5. Next Scheduled Court Date & Time
6. Visitor Name*
7. Relationship to the Child*

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
8. DOB*

MonthDayYear
Date
9. Race.*

African American/ BlackEuropean American/ WhiteHispanicOther
10. Address*
11. Phone Number*
12. Additional Visitor Name
13. Relationship to the Child

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
14. DOB

MonthDayYear
Date
15. Visitor Race

African American/ BlackEuropean American/ WhiteHispanicOther
16. Address
17. Phone Number
18. Does this visitation need to be wheel chair accessible?*

YesNoUnsure
19. Visitation Frequency*

1x Weekly2x WeeklyBi-WeeklyMonthlyOther
20. Length of Visits*

30 minutes1 hour2 hoursOther
21. Historically, when has visitation occurred?
22. Visitation Goals*

Supervised VisitationParental CoachingMaintain BondAppropriate Disciplinary SkillsDevelop Structure/ RoutineConsistency/ Time ManagementOther
Caregiver/ Placement Information
23. Placement Type (Choose all that apply)*

Foster Parent- Non RelativeRelative (indicate connection next to name)ParentGroup Home/ FacilityOther
25. Name*
24. Name, Address, and Phone Number (if multiple placements, please indicate the child's name next to the placement)*
27. Phone Number*

25. Child Name(s)*

	Child Name	DOB	Placement Contact (if different from above)	Medical Concerns/ Allergies	Gender
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information

26. Reason for Referral - Check all that apply*

AbductionAlcohol UseDomestic ViolenceDrug UseInadequate HousingNeglectMedical NeglectPhysical ViolenceSexual AbuseNot DFCS related
27. Why are the children in care? If applicable.
28. Permanency Plan*

AdoptionAPPLAConcurrent: Adoption with ReunificationConcurrent: Guardianship with ReunificationContinued Custody with ParentPermanent GuardianshipReunificationOther:
29. List the names of other individuals and their connection to the child(ren) who are Allowed to attend the visit.*
30. List Individuals and their connection to the child(ren) Restricted from Visitation.*
31. Are there any circumstances or areas of concern that The Bright House should be aware of with respect to the visiting parties.*
32. Have you arranged transportation? If so, please list person/ provider information.*
33. Please list the name of the Mother's Attorney*
34. Please list the name of the Father's Attorney*
35. Please list the name of the Child's Attorney/ GAL*
36. If you are not the case manager, please list the case manager's information. If CASA is assigned, then please list the name of the CASA (if known)*

Please upload Court Order*

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Please upload Case Plan

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Supervised Visitation Referral