Attorney Request for Services Form

Attorney Request for Supervised Access Services
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
Date
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
Date
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
Date
Person with whom Child 1 resides.*
Child 2's Name

First NameLast Name
Child 2's Date of Birth

MonthDayYear
Date
Person with whom Child 2 resides.
Child 3's Name

First NameLast Name
Child 3's Date of Birth

MonthDayYear
Date
Person with whom Child 3 resides.
Child 4's Name

First NameLast Name
Child 4's Date of Birth

MonthDayYear
Date
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.*

Every FridayEvery SaturdayEvery 2nd & 4th FridayEvery 2nd & 4th SaturdayEvery 1st & 3rd FridayEvery 1st & 3rd SaturdayOther
If "Other", please explain.
Please indicate the ordered duration of each session.*

1 hour2 hoursOther
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.*

Temporary Restraining OrderProtective OrderTemporary OrderPending ChargesChild Custody EvaluationChild CounselingN/A
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.

Cancelof
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.*

Cancelof
Please attach a copy of any Custody Evaluations completed.

Cancelof
Should be Empty:

Attorney Request for Supervised Access Services

Case Information