Wufoo

Date MM / DD / YYYY
Name First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number ### - ### - ####
Phone Number ### - ### - ####
email address
Relationship to child (ren)
custodial parent non-custodial parent other relative court ordered for visitation
name gender and date of birth of child/ren
Date of order, name of Judge, court, and docket number
Who is responsible for payment?
Other Parent Name:
Attorney Name and Phone Number
Do you pay or receive child support?
Is there a protection order in place?
Do you have weapons in your possession or in your home?
Is there a history of physical or verbal abuse against you or your children?
Have you used a visitation center before?
Have you been convicted of a crime?
Services Offered:
Monitored Exchange (Exchange of children from custodial parent and non-custodial parent) $5 per exchange per way. Suggested criteria: Concerns about safety and conflict eruption when parents exchange children for parenting time. Exchange will be facilitated by program staff only. No contact between parents, including exchange of written materials or money will be permitted. Details: The parent who is picking up the child/ren shall arrive 15 minutes prior to the time of the exchange and will wait in the visitation center. Custodial parent shall arrive at the scheduled exchange time to drop off the children with program staff. The parent who is picking up the child/ren shall leave first. The drop-off parent will leave 15 minutes after the pick-up parent and child/ren has left.

Fully supervised visits $40 per hour Suggested criteria: meet criteria for semi-supervised visits and/or concerns of ongoing physical or emotional abuse or neglect, risk of substance abuse by parent, mental health issues. General description: The program staff will be present for the duration of this visit. Their primary role will be to monitor the interactions between the parent and child and to intervene if/when necessary.

Semi-supervised visits $35 per hour Suggested criteria: threat of abduction, concerns of emotional or physical abuse or neglect. General description: Program staff will have minimal involvement in this visitation. Their primary role will be to occasionally monitor the interactions between the parent and the children, by “dropping in” to the visit, ensuring the safety of the children.

Details for fully or semi-supervised visits: Non-custodial parent shall arrive at the rear door of the visitation center located closest to the court house 15 minutes prior to the time of the visitation and will wait in the visitation center. Custodial parent shall arrive at the scheduled visitation time at the Bradeen St door. Child/ren will be brought to the visitation center by the program staff. UNDER NO CIRCUMSTANCES are the parents to have any contact with each other on our premises. The custodial parent will leave and the non-custodial parent will begin the visit. PICK UP: Custodial parent shall arrive at the scheduled time and wait for child to be returned by staff to the Bradeen St entrance. Non-custodial parent will wait in the visitation center. Children will be brought to custodial parent by the program staff. Custodial parent and child/ren shall leave the premises immediately. Non-custodial parent leaves 15 minutes after custodial parent has left. It is NOT the purpose of the Family Access staff to observe the visitation in order to make recommendations or give opinions to the referring party regarding custody. If the non-custodial parent requests that a third party participate in the visits, they must obtain a court order permitting this, or it must be an agreement of the Program Director and custodial parent.
PLEASE INITIAL IN THE BOX
Our Policies PLEASE READ CAREFULLY YOU WILL BE RESPONSIBLE FOR ADHERING TO THESE POLICIES:

Safety: One of the program’s fundamental responsibilities is to provide a safe environment for all family members and program staff. All of the policies and procedures have been developed with safety as the guiding influence. The Director will strictly enforce all policies and procedures with the assistance of staff. The program has established a ZERO tolerance policy regarding family violence and will not tolerate any exceptions by anyone. This position will help ensure safety for everyone and the proper delivery of services. If program staff suspect a visiting parent is under the influence of alcohol or drugs they will inform the custodial parent of their concern and cancel the visit. At that point the custodial parent will leave the facility and the non-custodial parent will leave 15 min. later. Staff: Staff or student interns will be conducting the exchanges/visitations under the direct supervision of the PRC Director. Confidentiality: Occasionally requests are made of the program to maintain contact with the children’s therapists, parent’s therapist, etc. in order to collaborate on the best interests of the child and family. This is only possible when both parents agree or the court orders such collaboration. In order to fulfill this request a release of information must be signed by both parents. Separate files will be maintained for custodial and non-custodial parents: Non-custodial parents file is not subject to release. Copies of records will be released only by subpoena of the non-custodial parent attorney. In the case that the parent is not represented by an attorney said records will be sent to the presiding judge or magistrate. Supporting documents regarding the custodial and non-custodial parent may be required to contain releases of information to the courts or documentation from agencies involved with the family to ensue coordination of services. Parents’ records do not enjoy the same privilege of confidentiality as with lawyers, physicians and therapists. Parents please be aware mandatory reporting laws for child abuse and neglect will supersede any policies at the Family Access Program. Please also be aware if a Guardian ad litem has been appointed to a family matter they will have access to Family Access observation forms and any written correspondence that is in the parent chart pertaining to the welfare of the child and does not require a release. Payment Policy: If not specified in the court order the non-custodial parent will be responsible for payment. Medication policy: FAMILY ACCESS PROGRAM STAFF WILL NOT ADMINISTER ANY MEDICATIONS DURING EXCHANGES OR VISITS. Transfer of medications during Monitored Exchanges: Prescription medication(s) may be transferred between custodial and non-custodial parents by program staff along with the children’s belongings. Each medication must be in its original container with the prescription label including physician’s name, child’s name, drug name, dosage and date. Program staff will assure compliance with this requirement and note all medications that are transferred in the program records. Non-prescription medication(s) may not be transferred. Child(ren)’s veto policy: It is NOT the responsibility of the Family Access staff to mediate, negotiate or investigate an issue with exchange/visitation. It is simply to provide a safe, secure and neutral place for parents and children to exchange/visit, not to force or otherwise compel an exchange/visit to take place. That would only serve to model power and control tactics, which would be inappropriate. The custodial and non-custodial parent will be informed of the child/ren’s right to veto an exchange/visit. The custodial parent is encouraged to arrive with the child/ren to fulfill the requirement of any court orders around exchange/visitation. It is in everyone’s best interests that the exchange/visitation is an enjoyable and positive experience for the child/ren. The veto may have nothing to do with either parent; it may simply be that the child/ren is out of sorts that particular day. It is also best that the child not come to associate negative feelings with any future exchange/visitation. If the child/ren resists an exchange/visitation, verbally or behaviorally, every attempt will be made to make the child/ren feel welcome and comfortable with the surroundings. The custodial parent should remain for a while initially to see how the child will tolerate the visit. If the child persists in their objections, the visit should be terminated and plans for the next exchange/visitation will be made with the custodial and non-custodial parents and child/ren. After the custodial parent and child/ren have left the building the non-custodial parent will be informed of the veto and of the efforts made to encourage the exchange/visitation in the future. Understand that only the day’s visit is forfeited, not all visitation.

In exchange for being accepted in the Family Access Program and services provided by PRC, I agree to abide by the following terms and conditions. I understand and acknowledge that if I violate these terms and conditions the program may report a violation of any of these terms and conditions to the court in the form of an incident report to terminate the agreement to provide services.
PLEASE INITIAL IN THE BOX
Family Access Service Agreement
1. I agree to provide all necessary forms and releases to the program
2. I agree to keep the program informed as to all current court orders or agreements with referring agencies in relation to child visitation, and abide by the terms of such orders or agreements.
3. I agree to pay to Parent Resource Center the fees associated with services according to the percentages set forth in the court order. Failure to pay will result in the suspension of visits until payment arrangements are made with the Director.
4. For supervised visitation the non-custodial parent agrees to use the rear door of the visitation center (located closest to the court house) and arrive at the center 15 minutes before the scheduled visit, and to remain at the center for 15 minutes after the conclusion of the visit and leave the premises immediately afterward. The custodial parent agrees to arrive at the Bradeen St entrance and wait for the staff member to meet the visiting child staff will bring child/ren to the visitation center, staff will return child/ren to the custodial parent at this entrance when services are complete. The custodial parent is responsible to inform the Family Access Program staff of his/her whereabouts during the visit. The custodial parent MUST provide a phone number where he/she can be reached during the visit.
5. No one may accompany the visiting parent to the visits (unless court ordered or agreed upon at intake or by request).
6. During monitored exchanges the parent who is coming to pick up the child/ren must arrive at the program 15 minutes before the scheduled exchange and then leave when the children arrive unless notified otherwise.
During monitored exchanges the parent who is dropping off the child/ren must arrive at the program at the designated exchange time and remain in the building for 15 minutes after the children have left.
7. Appointments that are cancelled or missed, with or without notice, may not be rescheduled. If 24 hour notice is not given the parent cancelling will be charged $25.
8. An appointment will be considered cancelled if the non-custodial parent arrives more than 10 minutes late a call to the center is necessary to avoid cancellation of visitation. Visiting(for full or semi-supervised visits) or pick up parent (for exchanges) ABSOLUTLEY must be in visitation center prior to the arrival of the child.
9. Upon two (2) cancellations without notice or three (3) consecutive cancellations with notice by either parent, a conversation will be had with Program Director to assess the continuation of services. This may involve loss of the current visit time and or a letter to be sent to the court letting them know that the court order is not being followed by the cancelling party.
10. Weapons are not allowed inside the center, and I agree that my person and belongings may be searched by the program staff, to ensure the safety of children and other participants and employees of the program.
11. Family Access program has a ZERO tolerance policy concerning drugs or alcohol use…thus, if we even suspect a person has been drinking or doing drugs we will terminate the visit/exchange.
12. Occasionally through a parental agreement as well as agreement of attorneys: we encourage the use of communication books between parties for information exchange regarding the children for visits outside the center. Staff will read all correspondence in communication books. Staff reserve the right to photocopy all correspondence. During on-site visits, the staff will only pass written information from one party to the other concerning the immediate care of the child(ren).
13. English is the only language that will be used during visits. If an interpreter is necessary, please inform the Director for assistance you will be responsible for obtaining interpreter services and fees associated. Speak to your child in a manner that can be heard by your supervisor. No whispering!
14. The non-custodial parent agrees to come to the visit prepared to care for child(ren). They are responsible for providing diapers, snack and meals during the visit. If there are foods which are inappropriate for the child(ren), the custodial parent will notify staff in writing prior to the first visit.
15. I understand that I will be solely responsible for child(ren) care while at the center. I am also responsible for cleaning up the room following my visit or exchange at the center.
16. Clothing, games, toys, books, pictures, money, letters, cards, and gifts may not be brought to the program without prior approval. Requests for permission to bring such items to a visit shall be made by calling the program at least four (4) days prior to the scheduled visit. EXCEPT for birthday and holidays if families spiritual beliefs allow for the celebration to occur.
17. Cameras for still photography are permissible unless the court order states otherwise. The camera is to be used according to visitation center rules. The use of recording equipment (e.g. video cameras, tape recorders) is not permitted by anyone at any time. We will allow a maximum of 4 still photos per visit. Cellphone use in our center is prohibited. If your cellphone is your camera then you may use it only for up to 4 still photos per visit.
18. A “positive visit” is one where both the child and non-custodial parent are relaxed and child does not have to worry about questions that s/he cannot answer, derogatory comments about the custodial parent, or any inappropriate touching or discipline. It is up to you as the visiting parent to make this a positive visit! Understand that the staff is here to assist you and answer any questions you have pertaining to the visit.
19. To help maintain a pleasant and child-friendly environment at the program, I agree not to engage in arguments, abusive language, use of profanity, inappropriate conversation, such as, but not limited to, a sexual theme, fighting, harassment, harm or threat of harm, loitering, or confrontation with any children, program staff member or other person at the center. Visiting parents may not talk about the custodial caregiver or extended family during visits. Physical punishment of children is NOT permitted at the center.
If it is reported by staff that non-custodial parent is in appropriate to staff member in their communication there will be one verbal warning and a decision will be made by staff whether or not services are to continue at our visitation center.
20. Records created and maintained by the program are confidential and their disclosure is limited as follows: A court appointed Guardian ad litem for the child may have access to their client’s file *observation forms* at the Family Access Program. A parent may not view the other parent’s individual file. Access to program records requires a subpoena. With a subpoena the records of the non-custodial parent and child observations shall only be released to attorney of the non-custodial parent or to the court.
21. An Intake Fee is required prior to initiation of any Family Access services. This fee of $100.00 includes the first hour of visitation or first exchange. This fee is non-refundable and is a fee not a deposit.
22. If staff is subpoenaed to court there will be a $50 per hour fee charged. This fee will be charged whether or not the staff is to testify when appearance has not been cancelled prior to the date of court this fee is due at the court house in form of check or money order made out to the Parent Resource Center. There is a $15 charge for records that are subpoenaed. There is a $50 per hour charge for consultation of staff with parent attorney(s).
25. These guidelines will remain in effect while you are involved with Family Access Program. All policies must be adhered to. Individuals will be informed of any changes in policies. My signature below indicates that I have reviewed the Family Access Program Agreement, that I have had the opportunity to ask questions regarding compliance and consequences of noncompliance and that I understand and agree to its terms.
Agreement will be signed and dated in person with staff as witness.
You will be asked to agree to these guidelines at your intake appointment if you want a copy of this form please feel free to print it.
Do Not Fill This Out