Family Intake Form

I am the following:

My Information

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Other Party Information

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Visiting Child

First NameLast Name

Gender

Child's Age

Child's DOB

Date

Visiting 2nd Child

First NameLast Name

Gender

Child's Age

Child's DOB

Date

Visiting 3rd Child

First NameLast Name

Gender

Child's Age

Child's DOB

Date

Please list any child specific health and safety issues:

These are not case specific, but only child specific.

Visit Details

Please list court ordered specific days and times for visitations or schedule availability, days and times:

These are not case specific, but only child specific.

At Pivotal Foundations, we offer safe child exchanges. Additionally, we offer transportation services, to and from visitations. Are these services being requested?

Please Summarize Court Order Requirements for Visitations

As stated in current finalized court order

Court Order

Please Summarize Safety Concerns Between Parties

No Contact Order (If Applicable)

Financially Responsible:

Parties On My End To Receive Visit Report

Attorney/Representation Information

First NameLast Name

Email

example@example.com

Addition comments/contact information for GAL or additional parties to receive report. Please also include emergency contact information for visiting parties.

Each party is responsible for their own $100 intake fee unless agreed upon otherwise. Intake fees are non-refundable, regardless of the on-boarding of a case. Pivotal Foundations, LLC places pride in the effort of our communications to set up services for each of our clients and will make every attempt to contact opposing parties to set up visitation services. All intake payments are collected below via Venmo or PayPal, from each party. Your intake is considered complete once this form has been signed and payment has been collected. The agreed upon time slot(s) for visit session(s) will then be reserved. *If you need to pay for both parties intake fees, please change quantity below to "2". Future payments for each session will be requested then collected via Venmo from the financially responsible party, prior to visitation. If you are not the party responsible for paying, please put N/A. Please list your Venmo Username below:

@username

I understand and acknowledge that Pivotal Foundations, LLC (“Provider”) and its Visitation Supervisors (“VS”) are neutral third-party supervised visitation service providers whose primary role is to promote child safety, observe interactions, document visitation activities, and assist in facilitating structured visitation services pursuant to court orders, agreements, or requested services.I understand that Visit Supervisors are mandatory reporters under applicable Oregon and Washington law and are legally obligated to report suspected abuse, neglect, threats of harm, safety concerns, criminal activity, or other reportable conduct to appropriate authorities or agencies when required by law.I understand that Provider and its representatives do not guarantee outcomes, reunification, custody recommendations, legal results, therapeutic results, or enforcement of court orders, and that all parties remain individually responsible for complying with any court order, parenting plan, custody agreement, or legal obligation applicable to their case.I understand that Provider and its representatives are not acting as attorneys, therapists, counselors, investigators, law enforcement officers, guardians ad litem, or legal decision-makers, and no legal advice, therapeutic advice, or custody recommendations are being provided.I understand that while reasonable efforts are made to promote safety during supervised visitation services, Provider cannot guarantee safety or control the conduct, actions, decisions, environments, or behavior of any party before, during, or after visitation services, exchanges, transportation services, or off-site activities.I further understand and acknowledge that communications, observations, interactions, behaviors, activities, statements, exchanges, transportation events, and incidents occurring before, during, or after services are not confidential and may be documented, retained, discussed internally for operational purposes, and disclosed when authorized, requested by court order, subpoena, mandatory reporting obligations, lawful request, safety concerns, or as otherwise permitted by law.I authorize and consent to Pivotal Foundations, LLC communicating with individuals or entities reasonably involved in the coordination, investigation, management, safety, or administration of this case, including but not limited to attorneys, legal representatives, caregivers, prior or future visitation providers, therapists, caseworkers, law enforcement, guardians ad litem, service providers, involved parties, and other individuals reasonably connected to the case or child(ren), as deemed appropriate by Provider for service coordination, scheduling, safety, documentation, or case management purposes.I authorize the release and exchange of information reasonably necessary for the coordination and administration of supervised visitation services and understand that factual observations, attendance records, policy compliance issues, scheduling matters, incident reports, and visitation documentation may be maintained and disclosed as permitted by law.I understand that Provider reserves the right, in its sole professional discretion, to suspend, deny, discontinue, refuse, reschedule, or terminate services at any time due to safety concerns, threats, harassment, policy violations, nonpayment, operational limitations, scheduling conflicts, inappropriate conduct, court order concerns, inability to safely provide services, or other legitimate business or safety-related reasons.I understand that supervised visitation services require advance scheduling, staffing, transportation planning, operational coordination, and reserved time allocation. I acknowledge that payment in full is required prior to scheduled services unless otherwise approved in writing by Provider.I understand that cancellations, refusals, failures to appear, or disruptions occurring within twenty-four (24) hours of scheduled services may result in forfeiture of scheduled visitation fees, administrative fees, transportation costs, or reserved scheduling costs, consistent with Provider policies and applicable law.I understand that if I request any owner, employee, contractor, Visitation Supervisor, or representative of Pivotal Foundations, LLC to attend court proceedings, hearings, mediations, depositions, meetings, consultations, testimony, or other legal-related appearances, I will be billed at double the standard company hourly rate currently in effect at the time of appearance, subject to a minimum two (2) hour charge per appearance. I further understand and agree that all travel time, mileage, wait time, preparation time, parking expenses, and additional time spent related to the requested appearance shall be billed separately in addition to the two-hour minimum appearance fee. All court appearance and legal proceeding fees must be paid in full no later than twenty-four (24) hours prior to the scheduled appearance unless otherwise approved in writing by Pivotal Foundations, LLC.I agree to comply with all Provider policies, procedures, scheduling requirements, safety rules, and visitation guidelines and understand that failure to comply may result in suspension or termination of services.To the fullest extent permitted by law, all parties agree to release, defend, indemnify, and hold harmless Pivotal Foundations, LLC, its owners, officers, employees, contractors, agents, and representatives from claims, liabilities, damages, losses, injuries, disputes, costs, attorney fees, or causes of action arising out of or related to participation in supervised visitation services, exchanges, transportation services, scheduling disputes, communications, documentation, court proceedings, third-party conduct, or actions of participating parties, except where prohibited by law or caused by gross negligence or willful misconduct of Provider.I understand that Provider may rely upon information provided by parties, attorneys, caregivers, agencies, or court documents and is not responsible for independently verifying the accuracy or completeness of information received.I acknowledge that this document serves as an intake acknowledgment and authorization form only and that additional visitation policies, procedures, agreements, financial terms, and service guidelines will be provided separately and remain fully enforceable upon execution.

Please read in entirety prior to signing

Payment

Intake Fee

This is a non-refundable payment required prior to submission.

$100.00 Quantity

Total

Payment Methods

Choose from one of the PayPal options to make your payment.

Family Intake Form

Payment*

Payment Methods

Payment