Attorney Request for Services Form

Attorney Request for Supervised Access Services
Hours of Operation

Wednesday 8:00 am - 12:00 pm

Thursday 8:00 am - 12:00 pm

Friday 9:00 am - 5:00 pm

Saturday 9:00 am - 5:00 pm

Supervised vists by appointment only.
Please fill out the following form in its entirety.
Petitioner's Full Name

First NameLast Name
Other names used (if any)
Petitioner's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Petitioner's Email
example@example.com
Petitioner's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Respondent's Full Name

First NameLast Name
Other names used (if any)
Respondent's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Respondent's Email
example@example.com
Respondent's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The Petitioner's relationship to the child(ren) receiving services.
The Respondent's relationship to the child(ren) receiving services.
Please list each child's name, birth date, and the name of the person with whom each child resides.
Child 1's Name

First NameLast Name
Child 1's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Person with whom Child 1 resides.
Child 2's Name

First NameLast Name
Child 2's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Person with whom Child 2 resides.
Child 3's Name

First NameLast Name
Child 3's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Person with whom Child 3 resides.
Child 4's Name

First NameLast Name
Child 4's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Person with whom Child 4 resides.
Other children named in the Order.
Case Information
Cause Number
Court Number
Judge
County and State
Service Requested
Please indicate the ordered frequency.
If "Other", please explain.
Please indicate the ordered duration of each session.
If "Other", please explain.
Petitioner Attorney

First NameLast Name
Legal Assistant Name

First NameLast Name
Petitioner Attorney's Email
example@example.com
Petitioner Attorney's Phone
Format: (000) 000-0000.
Petitioner Attorney's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Respondent Attorney

First NameLast Name
Legal Assistant Name

First NameLast Name
Respondent Attorney's Email
example@example.com
Respondent Attorney's Phone
Format: (000) 000-0000.
Respondent Attorney's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
An Ad Litem or Amicus Attorney has been assigned.
Ad Litem or Amicus Attorney Full Name

First NameLast Name
Ad Litem or Amicus Attorney Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ad Litem or Amicus Attorney Phone
Please enter a valid phone number.Format: (000) 000-0000.
Ad Litem or Amicus Attorney Email
example@example.com
Please list the names and phone numbers of other attorneys involved in the case.
Please select all that are active or pending.
Please provide an explanation for any selection made above. Enter "N/A" if no selection was made.
Please attach a copy of paperwork related to any selection made above.

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Please provide information about upcoming hearings (type, date, etc.).:
Please provide any important information related to safety concerns, mental illness, or other risk factors.
Please attach a copy of the Supervised Possession & Access Order.

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Please attach a copy of any Custody Evaluations completed.

Cancelof
Should be Empty:

Attorney Request for Supervised Access Services

Hours of Operation

Case Information