Family Intake Form
Request For Supervised Visitation Services
I am the following:
*
Please Select
Visiting Party
Custodial Party
Other
My Information
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Other Party Information
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Visiting Child
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Child's Age
*
Child's DOB
*
-
Month
-
Day
Year
Date
Visiting 2nd Child
First Name
Last Name
Gender
Please Select
Male
Female
Child's Age
Child's DOB
-
Month
-
Day
Year
Date
Visiting 3rd Child
First Name
Last Name
Gender
Please Select
Male
Female
Child's Age
Child's DOB
-
Month
-
Day
Year
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?
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Yes
No
Please Summarize Court Order Requirements for Visitations
*
As stated in current finalized court order
Court Order
*
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Please Summarize Safety Concerns Between Parties
No Contact Order (If Applicable)
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of
Financially Responsible:
*
Please Select
Visiting Party
Custodial Party
Both Parties
Other
Parties On My End To Receive Visit Report
*
Just Myself
Myself & Attorney/Representation
Other/GAL/CASA
Attorney/Representation Information
First Name
Last 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 plan 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 that my Visitation Supervisor (VS) is a Mandated Court Reporter and obligated to report any suspected or accurate child neglect and/or abuse. I understand that my VS is non-bias and placed at visitations to focus on child safety as well as documentations. I understand that it is my responsibility as well as the responsibility of the opposing party to fulfill my court order and that Pivotal Foundations, LLC will do so to the best of their knowledge. I understand that my VS cannot control safety outside of visitations. I further understand and acknowledge that none of the interactions, conversations, or activities are confidential (this includes before, during and after the following: exchanges, visitations, and transportations. This also includes any communication with clients and their perspective parties regarding this case and/or the child/ren). Interactions, conversations as well as activities may be documented in client visitation report and released to perspective parties and courts. I further agree and release information for the purposes of better understanding and investigating the needs of this case to Pivotal Foundations, LLC as well as allow communications if an applicable party involved in this case wants to contact Pivotal Foundations, LLC regarding services. I allow communications with needed parties to disseminate for the betterment of planning and communicating regarding my visitations and my case. I allow Pivotal Foundations, LLC and it's Visitation Supervisors to communicate with parties to include but not limited to past, present or future visitation providers, attorneys/representation, caregivers, parties involved with or pertinent to the case. All communications with be factual on behalf of Pivotal Foundations, LLC. All parties agree to release, hold harmless and indemnify Pivotal Foundations, LLC for any claims arising from the performance of any services provided by Pivotal Foundations, LLC, not limited to but including supervised visitation, transportation and/or exchanges. Should performance of Pivotal Foundations, LLC be interrupted by any occurrence which is beyond the control of our company, Pivotal Foundations, LLC shall be excused from performance of its obligations and undertakings. Pivotal Foundations, LLC reserves the right to discontinue services at any given time for any reason of choice to their clients or to any involved party. I understand that full payment is required prior to scheduled visitations (including a minimum of two billed hours, as well as transport time and or mileage, only when applicable) in order for the visit to occur. I understand that if the visit is cancelled within the twenty-four hour window, payment may not be reimbursed or credited. I will follow Pivotal Foundations, LLC policies and understand that if I do not services may discontinue. I understand that all efforts will be made by my VS to follow court orders/agreements as well as offer allotted visitation hours. I understand that these are not visitation guidelines listed in full, that I will receive those in a separate document to sign.
*
Please read in entirety prior to signing
Payment
*
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Intake Fee
This is a non-refundable payment required prior to submission.
$
100.00
Quantity
Payment Methods
Choose from one of the PayPal options to
make your payment.
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