Intake & Orientation Form

Today's Date

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What is your preferred way to receive messages?

What is your preferred language?

First NameLast Name

Please provide a current photograph for our file. This is essential for security purposes, as it allows us to verify the identity of the person picking up your child(ren) and ensure their safety.

What is your relationship to the child(ren)?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of birth?

Date

Email

example@example.com

Do you have any physical limitations or mobility restrictions that prevent you from climbing stairs?

What are your objectives in using the safe exchange program?"

Describe your vehicle:

Rows	Any thoughts?
Color:
Year:
Make:
Body Style:
Additional Info:
License Plate #:
State Registered:

Your emergency contact?

First NameLast Name

Emergency contact phone number

Please enter a valid phone number.Format: (000) 000-0000.

Co-parent Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What is their relationship to the child(ren)?

Do you know a way to contact the other party if there's no phone number?

Child 1 Full Name

First NameLast Name

Child(ren)'s Photo: Please submit a recent, clear photo of your child(ren). This image is essential for our records and helps our staff quickly and accurately confirm the child's identity.

Date of birth?

Date

List any allergies & special needs

Child 2 Full Name

First NameLast Name

Child(ren)'s Photo: Please submit a recent, clear photo of your child(ren). This image is essential for our records and helps our staff quickly and accurately confirm the child's identity.

Date of birth?

Date

List any allergies & special needs

Additional Child(ren)s Name, Date of birth, and any allergies & special needs. During orientation, our staff will help you upload their photos to our file for quick and accurate identification.

During orientation, our staff will help you upload their photos to our file for quick and accurate identification.

How will the Program Services be paid for?

Is there a referring agency? If yes who?

Agency Referral Date/If Applicable

Date

Reason for Safe Exchange Services:

Please list any Safety Concerns and Special Instructions you have about using the Safe Exchange Program through Ainsley's Playhouse?

Is there a Guardian ad Litem?

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Case Number (if applicable)

Is there an existing court order/stipulation

Marital Status

Protective or No-Contact Orders?

Has Law Enforcement ever been involved in an exchange?

History of Domestic Violence, Abuse, or High Conflict?

If yes, give a short description of the incident(s) that occurred:

File Upload

I, the undersigned, certify that the information provided on this form is accurate to the best of my knowledge.

I have read, understood, and agree to the policies and procedures of the safe exchange program. I understand that failure to comply may result in termination of services.

Safety
I understand that if any of the following occur:
High conflict/hostile situation between parties
A party appears to be stalking the other party
Any unsafe actions occur

If the staff member has the child(ren), they will stay with the staff member and be brought inside the building. And law enforcement may be called for assistance (this will be up to the discretion of the staff member) .

Fees & Exchanges
I acknowledge there is an initial intake interview with a non-refundable fee of $103.50 per parent/guardian. Unless, your fee is being paid by an agency or the other party.
The safe exchange fee is $10.50 for Exchanges at the Eau Claire Public Library/Walmart.

Contact Information for Ainsley's Playhouse
If you need assistance or have questions, email us at: info.ainsleysplayhouse@gmail.com
Feel free to call (715) 404-5248

Client Signature

Staff Signature

Staff Commitments for Safe Exchange Program
Upon the intake of a new client, our staff is committed to upholding the highest standards of safety, professionalism, and adherence to protocol.

I. Safety and Care of the Child(ren)
Child Safety: We will act to keep the child(ren) safe to the best of our ability throughout the entire exchange process.

Caring Supervision: Your child's comfort and engagement are our priority. During the brief 15-minute transition period, they will be supervised and welcome to enjoy our selection of books, building kits, and coloring activities.

II. Documentation and Legal Obligations
Accurate Record Keeping: We commit to keeping meticulous records of every exchange, documenting the precise date and time of arrivals/departures, the condition of the child(ren), and any notable observations or events. You have the right to request a copy of our session notes. We will process your request and provide the notes to you as promptly as possible.

Incident Protocol: We commit to immediately following established protocols for any major incident, which includes contacting law enforcement and/or Child Protective Services when necessary, and notifying program leadership immediately.

Mandated Reporting: We are mandated reporters and commit to immediately reporting any suspected child abuse or neglect, as required by law and our policies.

Truthful Testimony: If called upon to testify in court or in legal proceedings, we will be truthful, objective, and unbiased, providing factual accounts based solely on our direct observations and records.

Enforcement of Court Orders: We commit to operating strictly within the confines of the current, controlling court order or agreement governing the exchange, without making personal modifications or exceptions.

III. Professionalism and Communication
Confidentiality: We will maintain strict confidentiality regarding all client information and exchange details, except where mandated by law (e.g., court order, attorney requests).

Adherence to Protocol: We commit to following all established Safe Exchange Program Policies and Procedures for every exchange.

Impartiality: We commit to remaining impartial and treating both parties with equal respect and professionalism, maintaining a neutral position in all interactions.

Clear Communication of Status: If any unforeseen circumstance prevents us from performing the exchange, or causes a delay, we will notify both parties with as much advanced notice as possible, including an estimate of our new arrival/exchange time.

Respect for Boundaries: We commit to enforcing the established boundaries and rules of the Safe Exchange agreement (e.g., restricted contact between parties, defined waiting areas).

No Advice: We commit to never offering legal, medical, or psychological advice to clients, always directing them to consult with their respective professionals or the court.
Continuous Training: We commit to participating in all required ongoing training relevant to child development, safety protocols, conflict resolution, and legal mandates.

Zero Tolerance for Impairment: We commit to a zero-tolerance policy for staff impairment. Staff will not conduct exchanges if under the influence of any substance that could impair judgment or reaction time.

Staff Signature

Client Signature

Parent/Guardian Name

Co-Parent/Guardian Name

Child(ren)s Information

Safe Exchanges

Guardian ad Litem

Status and Case Information

Acknowledgment and Agreement