2HomeKids Inquiry

2HOME KIDS PROGRAM

Red * indicates a response is required.

Which Hannah's House service are you signing up for? *

Supervised Visitation Safe Exchanges

Case Number

Leave blank if unknown.

Name *

First Name Last Name

Are you the Custodial or Non-custodial Parent? *

Custodial Non-custodial

Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Alternative Phone Number

Area Code Phone Number

Email *

example@example.com

Other Party's Name

First Name Last Name

Other Party's Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Other Party's Phone Number

Area Code Phone Number

Other Party's Email

example@example.com

Who Referred You? *

Per the Court Order, who has LEGAL custody? *

Have you used Hannah's House services before? When? *

Who is the Family Court Services Counselor or Private Mediator?

Indicate NA if not Applicable

FCS Mediator or Private Mediator's Phone Number

Area Code Phone Number

Do you have an attorney?

If so, please provide name, address, phone number, and email if available.

Does the other party have an attorney?

If so, please provide name, address, phone number, and email if available.

Is there a Court Appointed Evaluator?

If so, please provide name, address, phone number and email if available. Indicate "NA" if Not Applicable.

Is there a Court appointed Therapist?

If so, indicate whose therapist it is, their name, address, phone number and email if available. Indicate "NA" if Not Applicable.

Children *

Please provide the ALL children's full name (as they appear in court order documentation), their dates of birth and the sex of each child.

Is there an attorney that represents the child(ren)? AKA Minor's Counsel *

Provide his/her name, phone number and email if available. Indicate "NA" if Not Applicable.

How long has it been since the children had contact with the Non-Custodial parent? *

Why is supervised visitation recommended in this situation? *

For example: due to a Restraining Order, due to child abuse, mental illness, etc.

How many hours per week are ordered? *

For example: due to a Restraining Order, due to child abuse, mental illness, etc.

Has there been a previous order for supervised visitation? *

If so, where did you receive services and the dates of services.

Next Court Date?

Date

Next Mediation Date?

Date

Is there any risk of flight/abduction on the part of either parent? *

Yes No

Are there any Restraining Orders in effect? *

Yes No

If YES to above question, please indicate Against Whom, Why and Expiration Date?

Is there a history or current concern about Domestic Violence? *

Yes No

Is there a history or current concern about Child Abuse (physical or sexual)? *

Yes No

If YES to above question, please indicate what type of abuse.

Is there a history or current concern about Alcohol or Drug Abuse? *

Yes No

If YES to above question, please indicate what type of alcohol or drug abuse.

Is there an order for alcohol or drug assessment/testing? *

Yes No

Do you smoke cigarettes around the child(ren)? *

Yes No

Please indicate if there are any legal issues pending that are related to the case. *

Indicate "NA" if no legal issues pending.

Please indicate if the child(ren) have any medical conditions, food allergies, or special needs that we should be aware of. *

Indicate "NA" if no legal issues pending.

Have you heard about out Transitions Family Program (psycho-educational & clinical services)? *

Yes No

I understand I will receive acknowledgement of receipt of this screening form within 48 hours and I will then be scheduled for a required new-client orientation. I also understand Hannah's House will start working on contacting the other party to also get them started on the intake process, if they have not already done so. *

I Agree

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