Bright House Visitation Referral

Supervised Visitation Referral

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

Please complete this referral in its entirety to enable us to create individualized safety plans and provide tailored services. Once we are in receipt of your referral, we will contact the parent/visitor within 3 business days to schedule an intake. The intake summarizes court orders (if applicable), Bright House's policies, procedures, and tailored safety plans.

After completion of the intake, the Bright House manager will contact the custodial party to complete the intake process as well.

The visiting parent or their attorney may request their visitation notes for a fee of $5 per monthly note.

Thank you,

Ja'Nae Brown
Bright House Manager
1. Date

MonthDay Year
Date
2. Referral County*
3. Referral Source*

Custodial ParentNon-Custodial ParentPrivate AttorneySuperior CourtOther
Referring Individual, Phone Number, & Email
4. Name*

First Name Last Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
5. Case Name*
6. Next scheduled court date and time
7. Visitor Name*
8. Relationship to the Child*

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
9. DOB*

MonthDay Year
Date
10. Race.*

African American/ BlackEuropean American/ WhiteHispanicOther
11. Address*
12. Phone Number*
13. Additional Visitor Name
14. Relationship to the Child

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherBrotherSisterOther
15. DOB

MonthDay Year
Date
16. Visitor Race

African American/ BlackEuropean American/ WhiteHispanicOther
17. Address
18. 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*

30 minutes1 hour2 hoursOther
23. Historically, when and where has visitation occurred?
24. Visitation Goals*

Supervised VisitationParental CoachingMaintain BondAppropriate Disciplinary SkillsDevelop Structure/ RoutineConsistency/ Time ManagementOther
Caregiver/ Placement Information
25. Placement Type*

Custodial ParentGroup Home/ FacilityRelative (indicate connection next to name)
26. Name*
27. Address*
28. Phone Number*

29. Child Name(s)*

	Child Name	DOB	Placement Contact (if different from above)	Medical Concerns/ Allergies
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information
Child(ren) Information

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.*
34. Has transportation been arranged for the child? Please list their information if it isn't the child's caregiver.*
35. Please list the name and contact information of all attorneys and mediators pertaining to this case.*

Please upload Court Order*

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Please upload Protective Order

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Supervised Visitation Referral