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Intake Form

All forms must be received & completed prior to scheduling visitations. 

Agreement for Services

Check one:


It is agreed that each PARENT/GUARDIAN and the Professional Provider make every effort to ensure child(ren) and visiting parent have a safe and enjoyable visit. To do so, the following procedures must be followed: 

Emergency Contact Person


I.          SCHEDULING

                      a.   The day/hours of visitation will be:

                      b.   Time of arrival for visit will be: 

                      c.   The frequency and duration of visits will be subject to the court order, which is/are: 

                      d.   I will arrive and depart from specified location                                                                                                        precisely at the prearranged

                             times. Repeated lateness will result in services being terminated. A 2-hour minimum is required for all visitation services.  


                       a.   I agree to pay a $40.00 Intake application / Screening fee. 

                       b.   I agree to pay $50.00 for each hour of Supervised Visitation, plus related expenses of/during visit (entrance and/or parking fees, etc.). I agree to pay for Providers meal only where specific activities or locations necessitate a meal purchase (Benihana Restaurant, American Girl restaurant, etc.). 

                       c.   If I or my attorney have subpoenaed the provider, and that person is required to make an appearance, I will be charged a flat fee of $500.00 for each day served. Payable in advance, in cash. 

                       d.   If I call and I am late for the visit, I will be charged $2.00 per minute after a 5 minute grace period. If I fail to arrive after a 20 minute waiting period, the visit will be cancelled and a cancellation fee will apply. The Cancellation fee will be equivalent to the already "Scheduled" visitation and must be paid upon the next schedule visit or before a new visit occurs. 

                       e.   If I cancel a visit within a 24 hour period, there will be a cancellation fee equal to the scheduled visit hour(s) and must be paid before the next visit begins. 


Per Family Law code 3200.5, Uniform Standards of Court 5.20, the following procedures are applicable to ALL supervised visitation cases where clients are being provided services. 

(g) Safety and security procedures

All Providers must make every reasonable effort to assure the safety and welfare of the child and adults during the visitation. Professional Providers should establish a written protocol, with the assistance of the local law enforcement agency that describes the emergency assistance and responses that can be expected from the local law enforcement agency. In addition, the professional Provider should:

5)   Establish and state in writing minimum security procedures and inform the parties of these procedures before the commencement of supervised visitation;

6)   Conduct comprehensive intake and screening to understand the nature and degree of risk for each case. The procedures for intake should include separate interviews with the parties before the first visit. During the interview, the Provider should obtain identifying information and explain the reasons for temporary suspension or termination of a visit under this standard. 

  • Provider will refuse to accept any case when the safety needs and risks presented by the family cannot be managed. 

  • Provider cannot guarantee safety; adult clients remain responsible and accountable for their own actions. 

  • During visitation, in the event of ANY emergency, Provider will first contact 911 (emergency services), then call custodial parent to make them aware of situation. 

  • Provider will know locations and phone numbers for police department, fire department, and hospital nearest to visit site. 

  • Provider is child and adult CPR/AED certified and carries a FIRST AID KIT to all visits. 

  • Provider will NOT allow any contact between custodial and noncustodial parents unless ordered by the court. 

  • Provider will NOT allow visit if noncustodial parent appears to be under the influence of alcohol or illegal drugs. 

  • Provider will ensure all contact with child(ren) and noncustodial party is within hearing and sight at all times and discussions are audible to Provider. 

  • Provider will record conversations, activities, and any critical incidents of each visit. 

  • Provider will NOT allow spanking, hitting, or threatening of the child(ren) during visitation. 

  • Provider will NOT allow herself or child(ren) to be used to gather ANY information about the custodial parent's whereabouts, activities, living arrangements, friends, associates, income, etc. 

  • Provider will NOT allow any additional people to attend visit unless listed on the court order. 

  • Provider has the right to search for PROHIBITED weapons if necessary before each visit. 

  • If any weapons are found, law enforcement will be contacted and supervised visitation services with contracted Provider will be terminated. 

  • Provider is a MANDATED REPORTER of child abuse and will report any suspected abuse to the appropriate agency as provided by law. 

In the event of CHILD ABDUCTION, Provider MUST... 

Call 911.

Provide law enforcement with information on the location of abduction.

Provide a description of the abducted child(ren).

Provide a description of the noncustodial parent (suspect). 

Provide a description of the vehicle involved. 

If Provider determine that the rules of the visit have been violated, the child(ren) have become acutely distressed, or the safety of the child(ren) or the Provider is at risk, the visit will be temporarily interrupted, rescheduled later, or terminated. 

Thank you for submitting! Please submit the documents listed below in order to move forward with your intake process. 

Intake Checklist


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