Intake Form For Clients of Supervised Visitation
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1 Intake Form For Clients of Supervised Visitation Bring 7 items to the Intake Appointment: 1. Copy of Court Order or written instructions for supervised visitation 2. Copies of Police Reports within the past 12 months, TPO, Violence, Abuse, Drugs, Alcohol. Weapons, 3. Copies of Arrest or Convictions Records within the past 12 months 4. Copy of Driver s License 5. Completed Intake Form 6. Fee for Intake Appointment: $75 Cash or Cashier s Check 7. Fee for First Visitation: Based on contract agreement Georgia Preferred Family Resource Hwy 92 Suite Woodstock, Georgia Client Information: PRINT ONLY Name: Address: Phone: Birthday: Driver s License Number: Copy of Driver s License attached: TAG # Fee agreement: Payment is due in 7 days in advance of each visitation. Please pay now for upcoming SV Collected Fee : Cash or Cashier Check Client Initial Intake Fee: Visitation Date/Time: Fee: 1
2 Child Information (complete for each child) Name: Date of Birth: age: Gender Race: Special Needs Provide Photo Childs Name: Date of Birth: age: Gender: Race: Special Need Provide Photo Additional children on back Attorney Information Name: Address: Phone: * Guardian Ad Litem Name: Address: Phone: * Judge Information Name: County: What are the instructions in the Court Order or paperwork for Supervised Visitation? Explain: Provide copies of all police reports, TPO s, Temporary Protective Order Who is the current caregiver of children: name and phone numbers (home, work, mobile): Name: Phone: Does the child(ren) have any physical challenges, developmental delays, areas of concern, medications, or special needs that may affect visits? 2
3 Custodial parent must provide all medicine or special needs PRIOR to visitation. We will not administer any medication nor allow visiting parent to administer medication during services. Yes I understand and will abide : Client initial: Does the child(ren) have any emotional or mental health issues that may affect visits? What is the grade level of the child(ren)? Are there any school problems or school-related behavioral concerns? Is the child(ren) currently involved with a therapist or in a therapeutic program? Contact information: Name: Scheduling the Supervised Visitation Visitation Information: On Site: Location Address: Off Site: Initial Location Date of first supervised visitation:, Visitation schedule (weekly, monthly, other) and duration (e.g., 90 minutes, etc.) Adults Involved in visitation: No other Adults will be allowed to participate in visitation unless all parties agree or it is stated in the court order. Name and relationship to child(ren): Emergency Contact: Name, phone, relationship: Marital status of parents: What is each parent s relationship with the other? How does each parent describe his/her relationship with the child(ren)? If out-of-home care, what is each parent s relationship with the substitute caregiver (relative, 3
4 Is anyone prohibited from visiting with the child(ren), either with or without a no-contact order? If so, identify by name and relationship to child(ren) Are there any topics that should NOT be discussed with the child, or in the child s presence? If so, identify: Are there any criminal issues or security concerns that should be noted? Recent arrests within one year or convictions within the last five years: Provide copies of arrest record and all convictions. Explain: Threatened to adduct child? Weapons, Drugs, Abuse Charges pending? Explain: Is there a history of or current allegations of domestic violence? Provide a copy of Danger Assessment screening for domestic violence. TPO Is there a history of Anger Management issues? Does either parent have any substance abuse issues that could affect visits? Current treatment or directions from the court: Does either parent have any physical or mental health issues, or any special needs that could affect visits and that SV program staff would need to be aware of prior to visits? Are there any parental employment (work hours) or other considerations needed when scheduling visits? Occasionally we need to release records and information to official contacts. Do you give permission to release information to official contacts only: Does each parent have access to or need information about available community resources? GaPFR would like to offer our services. Are you interested in receiving resources? Parenting Class Divorce Care Class Parent coaching Safe Exchange 4
5 Our staff wants to be sensitive to the diverse racial, ethnic, religious, and cultural influences that families bring to the program. What other concerns do you have about Supervised Visitation? Specific Policies and Procedures. These rules apply during any service rendered or appointment. Failure to comply may cause immediate termination and/or actions will be reported to court officials. If termination is necessary observer will make notes within observational report, call GAPFR, and/or contact law enforcement for assistance. Participants shall NOT exchange words, verbal or nonverbal gestures, towards other parents unless agreed upon prior to appointment or visiting situation. Participants shall NOT approach another person s vehicle unless given permission by monitors. Do NOT retrieve or return children to another s vehicle. Participants shall NOT use drugs or alcohol prior to or during visitation. Suspicion of narcotics/alcohol use will be noted in observation reports or result in termination of visit. No refunds will occur. Participants shall NOT smoke or use inappropriate language. Participants shall NOT use cell phones or cameras (leave in your car). Participants shall NOT bring pets/animals. (No pets allowed at Off-site locations. Some Observers are allergic to animals; CATS) Participants are NOT allowed to bring gifts/toys or other items unless it has been agreed upon with all parties. (Birthdays are the exception). Participants are NOT allowed to bring food, drinks or candy unless it has been agreed upon by all parties. Custodial parent/caregiver have the option to administer medication prior to scheduled times. Medication is NOT allowed to be administered during visitations. Participants are NOT allowed to bring sick children to visitations; fever of 100, diarrhea, vomiting, unexplained or contagious rash. Parents should be free of contagious conditions. All must be symptom free for 24 hours or taken medicine for 24 hours. Participants are NOT allowed to be alone with children. Observer will support bathroom needs or other situations. Participants are NOT allowed to speak in a foreign language. NO whispering. NO passing notes or cards unless openly shown to observer for approval. The observer will be reporting conversations at all times and must be able to fully understand all participants. 5
6 Participants are NOT allowed to use corporal punishment. No spanking, hitting, pinching to correct behavior. No inappropriate touches, fondling or suspicious physical contact. Participants shall NOT discuss inappropriate topics with children such as; living situations and people in home, abuse allegations of any type. If child becomes stressed the visitation may end before scheduled time. All personal information will remain confidential. There should never be an exchange or request for address, phone numbers, locations, or names from parents or children during any service or appointment. We do not give out information from forms unless contacted by a court official. Participants shall NOT engage observer or staff members in conversations regarding legal issues, court orders, or discussing other parent. Staff will remain neutral at all times. Do Not Talk to monitors about your case. Please focus on your children! Participants shall always provide correct contact information for each appointment or service. Services and appointments are restricted to the agreed location for duration no exceptions will be made. All Participants must comply with scheduled times, dates, and locations. Failure to do so will result in termination. Staggered Arrival and Departure times are extremely important for safety for all participants. Visits will begin at scheduled time and end at scheduled time. If party fails to pick children up at scheduled time, observers will wait 20 minute before calling police or assistance. Late fees will be charged at two dollars per minute. All fees are paid in advance. Payments can be made via Cash, Western Union. Cashier Check, Walmart Transfer, Money Order. Advance payment is at least 5 days prior to SV date. Typically clients pay for the upcoming SV on the date of the current SV. Advance payment will guarantee you the upcoming SV date. GaPFR will NOT hold a date unless payment has been received. Cancelations are made 48 hours in advance or no refund is allowed. Off-Site visitations may incur more flexible guidelines. These will be agreed prior to appointment or visit. These written policies are considered default guidelines. Observer may modify or change rules and guidelines to accommodate successful visits. I have read and understand policies and procedures. I agree and will abide by all stated policy, procedures, rules and guidelines. I understand the results of noncompliance can be termination of visit and lose of payments. Sign and Date: Payment $ 6
7 Visualize the Visitation Be Prepared and Arrive early : Payment Made out to Celeste Arnotti. 1. Greet monitor, pay advance fee and receive receipt for next Visitation. 2. Check valid Emergency numbers. 3. Check phone, keys, car tag# s. 4. Ask any questions of the monitor. 5. Greet children with Hello-Hug Time then enter play area. 6. Discuss agenda, rules, procedure with children. 7. Explain Goodbye-Hug Time (15 min warning then 2 min warning) 8. Ask any questions of the monitor. 9. Do Not approach other person s vehicle. Allow monitor to return children. I accept the rules of this contract. I will give at least seven day notice if Supervised Visitation is no longer required or lose advance fee. Client Sign: Intake Monitor Sign: Date: 7
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