Non-Monitored Parent Intake Form
Section 1: Court Case Information
What type of visitation is stipulated in your Court Order?
*
Supervised Visitation
Supervised Visitation in a Secured Facility
What's is your language preference for the visitations?
*
Please Select
English
Spanish
Romanian
For a language that is not listed here, please contact the office prior to filling in the intake form.
Court Case Number:
*
(e.g. FC2025-123456)
Petitioner:
*
First Name
Last Name
Petitioner's Legal Counsel:
Defendant:
*
First Name
Last Name
Defendant's Legal Counsel:
Best Interest Attorney (if applicable):
Court appointed evaluator (if applicable):
Back
Next
Save
Non-Monitored Parent Intake Form
Section 2: Non-Monitored Parent Information
Non-Monitored Parent/Person:
*
First Name
Last Name
Relationship to monitored children:
*
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your address court-protected?
Yes
No
What is your payment responsibility in percentage for the supervised visitations?
*
(e.g. 0, 50%, 100%, etc.)
Driver's license number:
*
Vehicle Make, Model and Year:
e.g. 2022 Toyota Prius
Vehicle color:
e.g. white, black, silver, red. etc.
Vehicle's license plate:
Please upload here a copy of your driver's license (front and back).
Browse Files
Drag and drop files here
Choose a file
If you have any issues submitting the files here, please e-mail them at contact@christiancareaz.com. Christian Home Care cannot process your intake application without the requested files.
Cancel
of
Please upload here a picture of your vehicle.
Browse Files
Drag and drop files here
Choose a file
If you have any issues submitting the files here, please e-mail them at contact@christiancareaz.com. Christian Home Care cannot process your intake application without the requested files.
Cancel
of
Please upload here a copy of your vehicle's insurance.
Browse Files
Drag and drop files here
Choose a file
If you have any issues submitting the files here, please e-mail them at contact@christiancareaz.com. Christian Home Care cannot process your intake application without the requested files.
Cancel
of
Back
Next
Save
Non-Monitored Parent Intake Form
Section 3: Legal Documents
Date the court order was issued pertaining to the supervised visitation:
*
-
Month
-
Day
Year
Court order date
How much parenting time was the Monitored Parent awarded?
*
Please indicate exactly as stated in the court order (e.g. maximum four hour per week)
Does any of the following supervised visitation restrictions apply to your case?
*
Secure Facility Required
Residence Restricted
Driving Restricted
Please upload the Court Order regarding supervised visitation.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have an Order of Protection (OOP) in place against the Monitored Parent/Person?
*
Yes
No
Please upload a copy of your OOP against the Monitored Parent/Person.
Browse Files
Drag and drop files here
Choose a file
If you don't have a copy at this moment, you can e-mail a copy at contact@christiancareaz.com. However, Christian Care AZ is not able to process the intake application until all requested documents have been submitted.
Cancel
of
Does the Monitored Parent have an Order of Protection (OOP) in place against you?
*
Yes
No
Please upload a copy of the OOP that the Monitored Parent has against you.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Save
Non-Monitored Parent Intake Form
Section 4: Monitored Parent Form
Monitored Parent/Person:
*
First Name
Last Name
Relationship to children:
*
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
Back
Next
Save
Non-Monitored Parent Intake Form
Section 5: Children's Information
How many children are included in the court order supervised visitations?
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
Please provide information for each monitored child:
*
Please use additional space to describe medical conditions that the Monitor needs to be aware of:
Have there ever been any allegations - substantiated or not - of emotional, physical and sexual abuse or neglect, regarding any of the children included in the supervised visitation? If yes, please describe. (Please skip if not applicable)
Back
Next
Save
Non-Monitored Parent Intake Form
Section 6: Supervised Visitation Availability
Please indicate your availability for your supervised visitation. A minimum of 2 hours is required for all booked sessions. We encourage you to fill in all available time slots.
*
When would you like the supervised visitations to start?
*
Please type additional information regarding your availability/scheduling preferences.
Back
Next
Save
Non-Monitored Parent Intake
Section 7: Approved Persons
Pease list the Approved Persons with the Monitored Parent/Person during the visits with the children.
In cases with no approved persons, you can leave this section empty.
Back
Next
Save
Non-Monitored Parent Intake Form
Section 8: Acknowledgment
Signature
*
Save
Continue
Continue
Should be Empty: