New Client Registration Form

Your Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number*

Please enter a valid phone number.

Your relationship to child / protected person*

Type of supervised visit or service:*

In-Office Supervised VisitationResidential Home Supervised VisitationCommunity Location Supervised VisitationVirtual or Phone visitationReunification or Parenting TrainingSafe Home InspectionPolice officer needed for safetyPre-Visit Drug Testing

Existing Court Order*

Yes, I have a valid court order for supervised visitationNo, I do not have an order; mutual parenting agreementMy order is expired

Date you believe visitation or services will start? *

Date

Please provide the names of all individuals who are authorized to be present during the visit with the child(ren), including any visitors. *

How often will visitations take place, according to the court order or as agreed upon between the parties? (ex: 1st, 3rd, weekends for 2hrs)*

How long will visitations last? (ex: 2hrs, 4hrs..etc)*

Where will visitations take place? Visitation locations should be pre-determined and mutually agreed upon by all parties, ensuring compliance with any applicable court order.*

Address or geographic area (City, County) that visitations will take place if within the community or a home:

If visitation takes place in a home, is the environment safe for both the child and the supervisor? If both parties do not agree on the safety of the location, a home inspection may be required.

Yes, the home is safe and I have no concernsNo, the home is not safe and I have concernsA home inspection needs to be completed prior to the first visitationNot applicable

How will the children be transported to the visitation location? Ensure that the custodial parent is informed and has agreed to the transportation arrangements.*

NON-CUSTODIAL PARENT: Name / Phone Number / Email Address*

Who is the primary caregiver for the children at this time? Please provide their name, email address, and phone number if known*

What method of communication do the custodial and non-custodial parties use? (App, text, email, phone, etc.)

Safe Time does not facilitate communication or negotiations between parties. In most cases, it is the non-custodial parent's responsibility to communicate and confirm the agreed-upon dates, times, and locations. If they are unable to communicate with the other parent, they should contact their legal representative for assistance.*

I understand and agree

List the full names and birthdates of the child(ren) or protected person: *

Supervised visitation is billed at a rate of $65 per hour for in-office, or $85 per hour off-site, with a minimum requirement of a 2-hour block. For visits involving more than two children, an additional charge of $20 per hour applies.*

I understand and agree

Brief and honest summary of events that led to supervised visitation being ordered by the court or agreed upon between the parties: *

When was the last time the child(ren) or protected person visited with the non custodial parent? Month and Year.

Is the non-custodial party in full compliance with all court-ordered requirements, including but not limited to protective orders, mandatory drug testing, and any other conditions outlined by the court or legal agreements?*

Has the custodial or non custodial parent been arrested within the last 12 months? If so, please list the exact charges and arresting agency.

Are any involved parties registered sex offender?*

YesNo

If a protective order is in place, please provide a brief summary of its restrictions (e.g., must maintain a distance of at least 100 yards).

Upload current court orders, protective orders, police reports, or other documents you feel are relevant.

LIMIT OF CONFIDENTIALITY

Communications, interactions, and activities are not protected by any privilege of confidentiality. Some personal information, including addresses and phone numbers will be removed from documents prior to being released.

Acknowledgment of limitations of confidentiality: By entering your name in the below box, you are indicating that you have read and are aware that confidentiality is limited and supervised visitation activities are not private, nor protected. There is no expectation of privacy.

I understand that a non-refundable $50 intake and orientation fee applies to each party. This fee includes account set up, communications with attorneys, gathering and review of records, face-to-face orientation, logistics and scheduling of the visitations.*

YES

I understand that all communication, reports, recordings, and other documentation will be sent directly to the clients, and it is the clients' responsibility to forward them to their attorney as needed. Documents and records will be generated after each supervised visit but will only be released upon the client's request via email.*

YES

FEES, GUIDELINES, TERMS, AND CONDITIONS:

Please review the terms and conditions at the link below. By checking the box and entering your name, you acknowledge and agree to the terms, including the waiver and release.

Enter your name:*

My Products*

$50 Intake & Orientation FeeThe orientation session can be arranged either through a phone call or Zoom and typically lasts around 30 minutes.

$50.00 Quantity

Total

$0.00

Payment Methods

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