Supervised Visitation Payment
Payments are due 24 hours in advance of your scheduled visit. Cancellations without 24 hours notice are not refundable.
Supervised Parent Name
*
First Name
Last Name
Child Name
*
First Name
Last Name
Child Name
First Name
Last Name
Scheduled Visit Date
*
-
Month
-
Day
Year
Date
Family Support Worker
CFC staff member
Payee Name
*
First Name
Last Name
Payee Phone Number
*
Format: (000) 000-0000.
Payee Email
Additional notes
Select one of the following. (One visit payment per transaction)
*
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( X )
1 Hour Supervised Visitation
$60/hr plus paypal fees
$61.80
$
61.80
2 Hour Supervised Visitation
$60/hr plus paypal fees
$123.60
$
123.60
3 Hour Supervised Visitation
$60/hr plus paypal fees
$185.40
$
185.40
4 Hour Supervised Visitation
$60/hr plus paypal fees
$247.20
$
247.20
30 min. supervised visitation (prior approval needed) $30 plus paypal fees
$30.90
$
30.90
Quantity
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