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*

Custodial GuardianVisiting PartyPrivate AttorneySuperior CourtOther
Referring Individual Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Case Name*
Next scheduled court date and time
Are you the person visiting?*

YesNo
Your Relationship to the Child*

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
Visiting Party's Name*
Their Relationship to the Child*

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
Their Phone Number*
Their Email*
example@example.com
Will anyone else attending the visitation?
Their Name
Their Relationship to the Child

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
Their Phone Number
Their Name
Their Relationship to the Child

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
Their Phone Number
19. Does this visitation need to be wheel chair accessible?*

YesNoUnsure
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).*

YesNoUnsure
21. Visitation Frequency*

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

1 hour2 hours4 hoursOther
What are the desired days/times for visitation?*
24. Visitation Goals*

Supervised VisitationParental CoachingMaintain BondAppropriate Disciplinary SkillsDevelop Structure/ RoutineConsistency/ Time ManagementN/AOther
Custodial Party Information
Who does the child(ren) live with?*

Custodial ParentRelative (indicate connection next to name)Other
26. Name*
28. Phone Number*
Email*
example@example.com
Child(ren) Information

29. Child(ren) Name(s)*

	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*

AbductionAlcohol UseDomestic ViolenceDrug UseDivorce/SeparationInadequate HousingNeglectMedical NeglectPhysical ViolenceSexual Abuse
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