Family Intake Form
Request For Supervised Visitation Services
I am the following:
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Please Select
Visiting Party
Custodial Party
Other
My Information
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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
Please list any child specific health and safety issues:
These are not case specific, but only child specific.
Visit Details
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Visit Availability
At Pivotal Foundations, we offer safe child exchanges. Additionally, we offer transportation services. 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
*
Browse Files
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Choose a file
Cancel
of
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/Emergency Contact Information for Visiting Party
Each party is responsible for their $75 intake fee. All payments are collected through Venmo (For intake: from each party. For visitations: from financially responsible party). A request from Pivotal Foundations, LLC will be sent to your Venmo, then you fulfill and submit payment. Your intake is considered complete once this form is signed and payment has been received. Please list your Venmo Username below:
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@username
I understand that my visit supervisor is a Mandated Court Reporter and obligated to report any accurate or suspected child neglect and/or abuse. I understand that my visit supervisor is non-bias and placed for visitations only and focused on child safety and documentations, I understand that it is my responsibility as well as the responsibility of the opposing party to fulfill my court order and that the visitation supervisor will do so as well to the best of their knowledge but cannot control safety outside of visitations or transportations. 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 transport. 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 visit report and released to perspective parties and courts. 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 Pivotal Foundations, LLC, 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 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 the cancellation policy listed on the Pivotal Foundations, LLC website and understand that all efforts will be made by my supervisor to offer allotted hours owed per court order, as well as owed make up hours, when appropriate.
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Please read in entirety prior to signing
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