SUPERVISED VISITATION/EXCHANGE INFORMATIONAL PACKET
Redefining You Therapy, Inc respects your right to privacy. This "Disclosure Statement & Agreement for Services" provided by Redefining You Therapy Incorporated follows HIPPA guidelines.
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Dear Parents,
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SUPERVISED VISITATION/EXCHANGE INFORMATIONAL PACKET (pg 2 of 7)
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Today's Date
*
Referred by:
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
Name & Relationship
Emergency Contact Phone Number
*
Please enter a valid phone number.
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SUPERVISED VISITATION/EXCHANGE INFORMATIONAL PACKET (pg 3 of 7)
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SUPERVISED VISITATION/EXCHANGE INFORMATIONAL PACKET (pg 4 of 7)
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SUPERVISED VISITATION/EXCHANGE INFORMATIONAL PACKET (pg 5 of 7)
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POLICIES
POLICIES FOR SUPERVISED VISITATION AND EXCHANGE SERVICES PREPARING THE CHILD FOR VISITATION AND/OR SAFE EXCHANGES
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SUPERVISED VISITATION/EXCHANGE INFORMATIONAL PACKET (pg 6 of 7)
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There is to be no Contact or Confrontation between parents during visitation/safe exchange
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I agree
No weapons or any article that could be used as a weapon are allowed on the premises
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I agree
The visit/safe exchange will not take place if you appear to be under the influence of drugs or alcohol
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I agree
Directions provided by the monitor must be followed. No discussion of the rules with the child present.
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I agree
There will be no food or drinks permitted during the visit
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I agree
There will be no food or drinks permitted during the visit
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I agree
Cell phones must be turned OFF during the visit/safe exchange
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I agree
Unless previously agreed upon, the parent(s) or guardian(s) will be the only person allowed at the visit/safe exchange
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I agree
You may not use the visitation for service of court documents
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I agree
Negative comments regarding the child(ren), the child(ren) placement, any agency’s involvement, the monitor, or any other caregiver will not be tolerated and may result in termination of the visit
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I agree
You may not pass correspondence or messages to the other parent (such as regarding legal matters) through child(ren) or monitor
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I agree
Sharing of detailed court information or court documents with the child/children and/or making of promises about future living arrangements, time sharing or visitation modifications. Visit discussions should focus on the present to avoid pressure and/or disappointment
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I agree
Speaking negatively about the other parent, his or her family or designee in front of the child/children and/or questions about the other parent’s whereabouts or activities will not be tolerated and may result in termination of the visit
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I agree
Inappropriate demands for physical contact, foul language, shouting, threats of violence or abuse, attempts to move child/children out of sight or hearing of monitor will not be tolerated and may result in termination of the visit
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I agree
All gifts must be pre-approved prior to the visit and monitor must receive notification at least 24 hours in advance
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I agree
You may bring your own toys and games to entertain your child during the visit. No outdoor toys allowed. Toys you bring with you go home with you, not the Child
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I agree
Children are not allowed to be taken out of the visitation room unless accompanied by the monitor
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I agree
The visiting person (if an adult) is responsible for managing the child’s behavior (Spanking, hitting or threatening will not be tolerated and may result in termination of the visit. The monitor will help if needed
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I agree
There is to be no talking down to the child(ren) using language to punish, embarrass, ridicule or demean them in any way. (Name calling, speaking loudly)
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I agree
The visitation room is your responsibility; it must be returned to its original condition prior to the end of the visit. Cleanup is to begin five minutes before pickup
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I agree
The visiting person should not try to appear lonely or needy. This may cause the child to worry or feel guilty
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I agree
There are to be no prolonged or tearful good-bye
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I agree
In no way is this list exhaustive. These are not all the rules and guidelines; others may be addressed as they arise. Failure to abide by these guidelines will result in reporting to the court or supervising authorities.
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I understand
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SUPERVISED VISITATION/EXCHANGE INFORMATIONAL PACKET (pg 7 of 7)
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E-Signature
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First Name
Last Name
Today's Date
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