Supervised Visitation Application – Long Form

Fields marked with an * are required.

Your First Name *

Your Last Name *

Address *

Name of Custodial Parent/Caregiver *

Name of Non-Custodial Parent/Caregiver *

Contact Phone: *

Email *

Driver's License Number *

Car Tag Number *

Car Make *

Car Model *

Car Year *

Car Color *

Employer *

Your Attorney *

Attorney's Phone Number *

Name of Child *

Date of Birth *

Age *

Grade *

Name of Child

Date of Birth

Age

Grade

Name of Child

Date of Birth

Age

Grade

Name of Child

Date of Birth

Age

Grade

Do you have a restraining order? *

Expiration Date *

If yes, mail a copy of your restraining order to:

Family Services Center

4092 Memorial Parkway SW

Suite 205

Huntsville, AL 35802

Have you called the police to enforce order? *

When did the most recent incidence of violence occur? *

When was the last visiting arrangements and why did they fail? *

Describe briefly the reasons for supervision: *

Mail court order to:

Family Services Center

4092 Memorial Parkway SW

Suite 205

Huntsville, AL 35802

Physical/Emotional/Sexual Abuse *

DHR Involvement *

Child's response to separation:

History:

Have you or the other parent ever been required to register as a sex offender? *

Date *

Which state? *

Do you or the other parent currently have an open DHR case in regard to your child(ren)? *

If so, what county?

DHR Worker First Name *

DHR Worker Last Name *

DHR Worker Phone Number *

Domestic Violence? *

Alcohol/Drug Use? *

Drug of Choice

Required Treatment? *

Where?

History or diagnosis of mental health issues? *

Please explain:

Do you have a criminal history? *

Please explain:

Anything else you think we should know:

Emergency Contact Information

Please list someone other than yourself who we may contact in case of an emergency.

First Name *

Last Name *

Relationship *

Address *

City *

US States *

Zip *

Home Phone *

Work Phone *

Cell Phone *

Authorization For Disclosure Of Confidential Information

First Name *

Middle Initial

Last Name *

Date Of Birth *

1. I hereby authorize

Name of FSC Staff Member

of Family Services Center to disclose confidential information from my client file. This information will be disclosed to the following:

First Name *

Last Name *

Phone *

Agnecy

Address *

City *

US States *

Zip *

Information to be disclosed from: *

to: *

includes the following: Issues regarding Supervised Visitation Services.

3. I authorize this disclosure for the purpose of exchanging information regarding Supervised Visitation.

I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Family Services Center, its employees, directors, and volunteers are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

(Specify the date, event, or condition upon which this consent expires.) *

Client's Signature (Parent/Guardian, if minor) *

Date *

Agreement to Pay Court Testimony/Document Authentication Fee

I understand and agree that should I cause any staff member of the agency to be subpoenaed into court for any reason (testimony or to authenticate documents), I will be personally responsible and liable for the court testimony fees incurred.

There will be a prepaid charge of $300.00 (2 hours minimum/$150 per hour) for each staff member requested to appear in court and/or be requested to be "on call/standby". Your prepaid charge must be paid in full by no later than the Thursday before your scheduled court date on the subpoena.

In addition, a fee of $150.00 an hour will be charged thereafter for all time an/all staff are absent from Family Services Center.

*Failure to render payment will result in visitations being suspended until payment is received.

No sliding fee scale will apply.

Full Name *

E-Signature *

Date *

Confidentiality And Mandated Reporting

All identifying information for each party will be kept confidential and not disclosed to any party unless authorized in writing by that party, or ordered by the court. Communication between monitor and the parties is not confidential and not protected by any legal privilege. However, the monitor will, whenever possible, attempt to safeguard the privacy of all parties. Further, the monitor is specifically required under Alabama State law to report to the appropriate agency information learned from any party or observed during visitation regarding the following:

â¢ Child abuse and neglect, including physical abuse and sexual abuse.

â¢ Dependent adult or elderly abuse, including physical abuse, sexual assult, neglect, abandonment, and fiduciary abuse.

â¢ Intent to harm oneself or others.

First Name *

Last Name *

E-Signature *

Date *

Basic Program Information

This agreement is intended to supplement the terms of the current court order, and under no circumstances will individual items of this agreement be imposed in contradiction of the current court order. Any questions regarding legal matters are to be addressed through an attorney or the court.

Basic Program Information

1. Supervised visitation is intended to provide a safe context in which the child may visit with the non-custodial parent. Discussion about unresolved issues or feelings with the child that exist between each parent is not allowed. No references about the other parent to the child (whether positive or negative) is to occur during the visit.

2. The visiting parent shall arrive at FSC front entrance 15 minutes before the scheduled start time. All visitors will not leave the FSC visitation room without staff permission. Any persons transporting the visiting parent shall vacate the premises immediately after drop-off. All visitors will leave FSC via the front entrance, 15 minutes after the visit has ended. All visitors will park in the parking area designated by Both Parents program staff. Violation of this guideline at any time may result in termination of visitation.

3. Conversation with the monitor will be kept to a minimum to encourage quality interactions between visiting parties and their children. Staff's interactions with all parties may be documented. Conversations with either parent will be limited to issues related to the visitation. Clients who demonstrate a need for this type of interaction will be provided with a counseling or conflict resolution referral, Clients are responsible for paying for this service separate from visitation services.

4. While it is not our desire to become involved in the legal process, it is important to note that the requesting parts responsible for subpoena's will be responsible for all document production fees and any court/legal appearance fees. Should any staff be ordered to appear the client requesting the appearance will be charged the appearance fee, which is to be paid in full prior to any staff attend the hearing of.

5. All unusual incidents will be documented and reported to the court and all parties as appropriate.

6. Should you have legal concerns at any time, please address them with your legal counsel and not FSC staff, as we are not qualified to provide legal counsel.

Program Guidelines

The following guidelines are intended to provide a safe, positive environment for the child, with consistency and predictability for everyone involved, and to minimize misunderstandings between parties.

1. Punctuality is crucial. Time noted on sign-in sheets is based on Both Parents Program time clocks only.

â¢ If a party is late, the facility may or may not be able to accommodate an extended time & may end at the originally scheduled time.

â¢ If the visiting parent is more than 15 mins late, the visit will be cancelled & the visiting parent will be charged the designated fee for that hour.

â¢ If a visit needs to be cancelled & it is after standard office hours. Email familyservices@fsc-hsv.org so that we can notify the other parties.

â¢ FSC requires 24 hours notice of visit cancellation. If a visit is cancelled the same day or the visiting parent does not show at all, FSC will charge the designated fee for that hour.

2. Parents will avoid one another by using the separate entrances at separate times. If you suspect a parent is in the parking lot, inform staff immediately; do not approach the other party.

3. The residential parent will arrive at agreed upon time and ensure that the young children have all needed supplies (snacks or diapers), unless other arrangements have been agreed upon between parties.

4. The visiting parent is responsible for assuming for assuming the full parental role during visits, including limit setting when necessary for the safety of the children and others involved in the visit. Visiting parents may assist in toileting as long as the door remains open in order to be supervised. Visiting parents may change diapers unless there are child sexual abuse allegations.

5. Video recording may be done on all or some of the visits by staff for security reasons; videos are not maintained as part of the permanent record. All visits are documented on a visitation report form and maintained in the client file.

6. Each visitor is subject to the security policy of the program. Staff may take all keys, cell-phones, purses, etc. into safekeeping at the beginning of each visit.

7. Any suspected drug/alcohol use will result in immediate termination of the visit and a request that the parent submit to a drug screen before another visit is scheduled. All fees associated with the drug screen are the responsibility of the parent in question. Any weapon discovered by security of staff will result in termination of the visit and all services by FSC and notification to the Court (NO EXCEPTIONS).

8. The visiting parent is responsible for ensuring that all FSC toys and other property are properly cared for and put away at the end of the visit.

9. If the guidelines have been violated, the child has become acutely distressed, or the safety of the child or monitor is at risk, the monitor will interrupt the visit and may either give the visitor a warning or terminate the visit immediately. All interruption or terminations of visits while in progress will be recorded in the Supervised Visitation Report.

I understand the guidelines & attendance policies:

Full Name *

E-Signature *

Date *

The Visit

1. Parents agree to arrive alcohol, tobacco, and drug free. Visit will be cancelled if substance abuse is suspected and a negative screen will be required prior to the next visit.

2. The visit should focus on the present so that the child experiences a calm and pleasurable visit. References to the past events which may have caused stress/trauma to the child should be avoided in discussions with the child. Discussion of future plans should also be avoided.

3. Visiting parents can invite, but not demand or coerce, physical contract with the child.

4. Use appropriate language.

5. Visiting parents must remain in the visit room and speak in conversational tones, whispering and passing notes are not permitted.

6. Parents will speak respectfully of the other parent, family members, or professionals involved in the family's case. Parents will not use their child or the program staff to pass documents or personal possessions between the parties.

7. If there is an issue to discuss with staff, parent will fo so outside of the visitation time while children are not present. If there is an issue with the monitor, parents are to contact the program director to review the situation. If there is no resolution then questions and concerns are to be directed to the executive director 256.551.1610.

8. If your child asks about the terms of visitation/custody/court orders or about future outcomes, state that the visits will be at FSC and we will let them know when that changes. Parents will not initiate discussion about the Court or other parent.

9. The visiting parent will use positive methods of discipline, i/e speak to child, redirect the behavior, address behavior by removing toy or item, or use a short time out in the room.

10. Parents are encouraged to play with child and have fun, ensuring it is age appropriate.

11. Asking probing questions such as "Do you love me?" "Do you miss me" "Why.... or why not" is prohibited.

12. Parents should not make any promises concerning any future visitations issues.

13. Parents are welcomed to bring gifts and food for their children, unless it is a health issue or prohibited by a Court Order. Parents are to show staff what is brought when entering the visit room.

14. Parents are free to take pictures during the visit, unless otherwise ordered by the court or in cases of alleged child sexual abuse. No video/audio recording will be done by parents. All cell phones must be put on silent and not answered during the visit.

15. Parents cannot approach each other, even through a third party, including having legal papers served to the other parent at FSC or on approach/leaving the visit. Any breach of this rule may result in immediate termination of all services and notification to the Court.

16. Parents will let children know they are loved; however, it is important to ensure your child does not feel responsible for your feelings or situation.

17. Altering the child's appearance (changing the child's clothing, non-permanent tattoos, cutting hair) is not allowed. However, re-combing or re-styling minor's hair, clear or colored fingernail polish, age appropriate makeup (i/e playing dress up) is acceptable; as such activities are part of the child/parents bonding experience. Parents are not required to ask permission from the other parent or caregiver to engage in such play activities unless prohibited by the court order.

18. Parents will assist child in entering and leaving the visit in a positive manner. Therefore, a prolonged goodbye by a parent is not permitted.

Fees, Scheduling and Logistics Of Visits

1. Supervised Visitation services are provided at $40 per hour (please see visitation costs at the bottom). If the Court's order does not specify, the cost will be charged to the visiting parent. Fees will be collected prior to the beginning of the visit. Fees in arrears must be paid prior to next visit.

2. Cancellation of visits must be made at least (24) hours in advance, except in the case of illness or emergency. In the event that one party does not arrive for a visit, or call to cancel, services will be terminated and the late party billed. Remember that cancellations affect your child.

3. If one parent has no arrived by 15 minutes after his/her scheduled arrival time without notification to FSC, the visit will be cancelled and the late parent billed for the missed visit.

4. The Both Parents Program Director bases scheduling on availability of time slots. The program will at all times attempt to adhere to the Court's Order and the Program Director will determine the times and dates of the visits. Specific scheduling needs of parents will be considered should work, school or mandatory conflicts arise. Availability of FSC staff will affect scheduling of visits after hours and on weekends. any change in schedule must be approved in advance by the Program Director.

5. ALL OUT-OF-STATE visiting parents are required to confirm each visit at least SEVEN (7) business days (M-F) before the scheduled visit or the visit may be cancelled. This requirement is waived for visits that are on consistent schedule.

6. Relative visitation will be allowed at the discretion of the Program Director or by DHR if applicable, as deemed in the best interest of the child(ren). Relatives (blood relation, marriage, siblings) are allowed to visit one time monthly as pre-arranged through the Program Director, unless prohibited by the Court. All adults participating in a visit must provide all requested information (legal ID) prior to engaging in visitation and must follow the guidelines of the program. Any non-scheduled visitor who arrives without prior approval of the Program Director will not be allowed in the visit. NO EXCEPTIONS. Any visitor who does not comply with the program guidelines will not be permitted to attend visitation.

Visitation Costs: 1 hour ($40), 2 hour ($75), 3 hour ($100), 4 hour ($120)

E-Signature *

Date *

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