New Client Registration Form

New Client Registration Form
Type of supervised visit:*

Virtual visitationPhone visitationIn person supervised visitationReunificationForensic InterviewSafe Home Inspection
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 visitation or services will start? *

MonthDayYear
Date
Where visits will take place?

Community location (ex: Public park)Residential homeVirtualPhone visit
CUSTODIAL PARENT: Name / Phone Number / Email Address*
NON-CUSTODIAL PARENT: Name / Phone Number / Email Address*
Your Full Name*

First NameLast Name
Your Date of Birth*

MonthDayYear
Date
Your relationship to child / protected person*
Does your address/phone number need to remain confidential?

Yes, it should remain confidentialNo, it is not confidential
Phone Number*
E-mail*
example@example.com
List the full names and birthdates of the child(ren) or protected person: *
Brief and honest summary that led to supervised visitation: *
When was the last time the child(ren) or protected person visited with the non custodial parent? Month and Year.
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
Upload current court orders, protective orders, police reports, or other documents you feel are relevant.

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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, not protected. There is no expectation of privacy.
Enter your name:*
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, etc, will be transmitted directly to clients, and it is the clients' duty to pass them on to their attorney.*

YES
FEES, GUIDELINES, TERMS, AND CONDITIONS:

Please review the terms and conditions located at the following link. Please note that you are signing the waiver and release by checking the box below.
My Products*
prevnext( X )
$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

Please click one of the PayPal options to complete payment and submit the form.
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