Bright House Visitation Referral

Supervised Visitation Referral

Savannah, GA 31401 | 912-447-8908 | 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 with the visiting party and the custodial guardian. After completion of the intake, Bright House staff will notify the parties of the visitation schedule.
Date

MonthDayYear
Date
Referral Source

Other
Referring Individual Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Case Name
Next scheduled court date and time
Are you the person visiting?
Your Relationship to the Child

Other
Visiting Party's Name
Their Relationship to the Child

Other
Their Phone Number
Format: (000) 000-0000.
Their Email
example@example.com
Will anyone else attending the visitation?
Their Name
Their Relationship to the Child

Other
Their Phone Number
Format: (000) 000-0000.
Their Name
Their Relationship to the Child

Other
Their Phone Number
Format: (000) 000-0000.
19. Does this visitation need to be wheel chair accessible?
20. Does this visit require parental coaching? (Coaching is optional and must be agreed upon by both parties or a decision the non-custodial parent chooses to receive).
21. Visitation Frequency

Other
22. Length of Visits

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

Other
Custodial Party Information
Who does the child(ren) live with?

Other
26. Name
28. Phone Number
Format: (000) 000-0000.
Email
example@example.com
Child(ren) Information

29. Child(ren) Name(s)

Rows	Child Name	DOB	Medical Concerns/ Allergies
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Referral Information
Are there any current protective orders?
30. Reason for Referral - Check all that apply
31. Are there any circumstances or areas of concern that the Bright House should be aware of with respect to the visiting parties.
32. List the names of other individuals and their connection to the child(ren) who are allowed to attend the visit.
33. List individuals and their connection to the child(ren) restricted from visitation.
If someone other than the custodial guardian is transporting the child(ren), please provide their name and contact information.
Visiting Party's Attorney Name & Email
Child's GAL Name & Email
Custodial Guardian's Attorney Name & Email
35. Please list the name and contact information of all attorneys and/ or mediators pertaining to this case.

Supervised Visitation Referral

Referring Individual Information

Custodial Party Information

Child(ren) Information

Referral Information