Supervised Visitation Intake Form

Supervised Visitation Intake Form

Bay Area & Calaveras County Supervised Visitation Confidential Intake Form This form is used to gather basic case information before supervised visitation or exchange services begin. Completion of this form does not guarantee that services will be accepted, scheduled, or confirmed
Parent / Participant Information
Name

First NameLast Name
Your Role
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Language
Preferred Method of Contact
Do you need a Spanish-speaking monitor if available?
Other Party Information

Please provide information for the other parent, guardian, or party involved in this supervised visitation case.
Other Party’s Full Name

First NameLast Name
Other Party Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Party’s Email
example@example.com
Other Party's Role
Child Information
Child’s Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current age (if date of birth is unavailable)
Are there additional children included in this case?
Yes or No
If yes, please list each additional child’s name, age, and any important needs.
Please describe any medical needs, allergies, developmental needs, behavioral concerns, or special accommodations the monitor should know about.
Is there anything that helps the child feel comfortable, calm, or safe?
Court / Case Information
Court County
Case Number
Is there a current court order for supervised visitation or exchange?
Is there a restraining order, protective order, or no-contact order currently in place?
Please upload the current court order, written agreement, restraining order, or other relevant documents.

Cancelof
Requested Services

What service are you requesting?
Which service are you requesting?

Other
What is the basis for the requested service?
How long is each visit expected to be?
Example answer: 2 hours, 4 hours, as ordered
How often are visits expected to occur?
Example answer: Weekly, monthly
Who is responsible for payment according to the court order or agreement?
Safety and Background Information
Are there any current safety concerns the monitor should know about?
Are there any concerns about either parent arriving under the influence of alcohol, marijuana, illegal drugs, or non-prescribed substances?
Are there any concerns about weapons, threats, intimidation, or unsafe behavior?
Are there any concerns about the child being coached, pressured, questioned, or exposed to adult conflict?
Please provide any additional information that may help the monitor maintain safety and neutrality.
Scheduling Availability
Please list your general availability for orientation.
Example: Mondays after 3:00 PM, Wednesdays before noon, weekends only, flexible schedule, etc.
Please list your general availability for visits or exchanges.
Example: Saturdays, every other Sunday, weekday evenings, per court order, flexible, etc.
List dates or times that cannot work, plus any upcoming court dates, deadlines, or requested start timing.
Are there any upcoming court dates, mediation dates, deadlines, or requested start dates?
When did the child last have contact with the visiting parent, and was that contact supervised?
What usually helps if the child becomes anxious, overwhelmed, upset, or reluctant to participate?
Who will transport the child to and from visits or exchanges?
Does the court order or written agreement require separate arrival, departure, parking, waiting, or no-contact procedures?
Please describe the separate arrival, departure, parking, waiting, or no-contact procedures.
Is anyone besides the visiting parent and child authorized or expected to attend?
Please list the names, relationship to the child, and authorization source.
Is there anyone who must not attend, approach, transport, photograph, record, or communicate with the child?
Please describe any restrictions or exclusions.
Does anyone need an interpreter, disability accommodation, communication support, or an accessible location?
Please describe any interpreter, accessibility, or communication needs.
Has this family previously used supervised visitation or exchange services?
Provider name
Approximate dates
Professional contact
Name

First NameLast Name
Role
Organization
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Acknowledgment and Signature
I understand that this intake form is used for initial review and does not guarantee that services will be accepted, scheduled, or confirmed.

I understand that all services are subject to review of the current court order or written agreement, safety considerations, program policies, monitor availability, and completion of all required forms, orientation, documentation, and payment arrangements.

I certify that the information provided is true and accurate to the best of my knowledge.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Supervised Visitation Intake Form

Parent / Participant Information

Other Party Information

Child Information

Court / Case Information

Requested Services

Safety and Background Information

Scheduling Availability

Professional contact

Acknowledgment and Signature