Foster Care Visitation Referral

Supervised Visitation Referral

Savannah, GA 31401 | 912-447-8908 | info@brightsideadvocacy.org
Thank you for choosing Bright House to provide safe and supervised visitation to the families in our community. Bright House will ensure that visitations occur in a controlled environment to maximize developmentally appropriate interactions in a home-like setting for our families.

Please complete this referral in its entirety. Upon receipt, we will contact the parent/visitor within three business days to schedule an intake. After completion of the intake, Bright House staff 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 Bright House one week prior to your desired visitation.
Date

MonthDayYear
Date
Referral County
Referral Source

Other
Referring Individual, Phone Number, & Email
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Next Scheduled Court Date & Time
Date of Next Court Hearing

MonthDayYear
Date
Visiting Party Information
Visiting Party's Name
Relationship to the Child

Other
8. DOB

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Will anyone else attend the visit?
Additional Visitor Name
Relationship to the Child

Other
Additional Visitor Name
Relationship to the Child

Other
14. DOB

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Does this visitation need to be wheel chair accessible?
Visitation Frequency

Other
Length of Visits

Other
What are the desired days/times for visitation?
Visitation Goals

Other
Visiting Child(ren) Information

Please provide all requested information.

Child Name(s)

Rows	Child Name	DOB	Placement Name and Number	Medical Concerns/ Allergies	Gender	Race/Ethnicity
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information

Referral Information
Reason for Referral - Check all that apply
Permanency Plan
List the names of other individuals and their connection to the child(ren) who are allowed to attend the visit.
List Individuals and their connection to the child(ren) restricted from visitation.
Are there any circumstances or areas of concern that Bright House should be aware of with respect to the visiting parties.
If visitation is already occuring, please provide transporter name and phone number.
Mother's Attorney
Father's Attorney
Child's Attorney/GAL
CASA
DFCS Case Manager
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)

Supervised Visitation Referral

Referring Individual, Phone Number, & Email

Visiting Party Information

Visiting Child(ren) Information

Referral Information