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*

DFCSJuvenile CourtAttorneySuperior CourtCASA (please include name of coordinator)Other
Referring Individual, Phone Number, & Email
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
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*

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
8. DOB

MonthDayYear
Date
Phone Number*
Email
example@example.com
Will anyone else attend the visit?

YesNo
Additional Visitor Name
Relationship to the Child

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
Additional Visitor Name
Relationship to the Child

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
14. DOB

MonthDayYear
Date
Phone Number
Does this visitation need to be wheel chair accessible?*

YesNoUnsure
Visitation Frequency*

1x Weekly2x WeeklyBi-WeeklyMonthlyOther
Length of Visits*

2 hoursOther
What are the desired days/times for visitation?*
Visitation Goals*

Supervised VisitationParental CoachingMaintain BondAppropriate Disciplinary SkillsDevelop Structure/ RoutineConsistency/ Time ManagementOther
Visiting Child(ren) Information

Please provide all requested information.

Child Name(s)*

	Child Name	DOB	Placement Contact (if different from above)	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*

AbductionAlcohol UseDomestic ViolenceDrug UseInadequate HousingNeglectMedical NeglectPhysical ViolenceSexual AbuseNot DFCS related
Permanency Plan*

AdoptionAPPLAConcurrent: Adoption with ReunificationConcurrent: Guardianship with ReunificationContinued Custody with ParentPermanent GuardianshipReunificationOther:
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