Visitation Form Multi-Step Intake Form 1 2 3 4 5 6 Custodial / Non Custodial Parent Parent Type * Select Parent Type CUSTODIAL NON-CUSTODIAL Case Information Court Case Number * Intake Date * Next Personal Information Full Name * Date of Birth * Home Address * Driver License No * Email * Primary Language Spoken * Home Telephone No * Cellular No * Work Telephone No * Previous Next Employment Information Occupation * Work Hours and Days * Employer Name and Address * Vehicle Information Make and Color of Car * License Plate * Previous Next Visitation Information Reason for Supervised Visit * Ordered by the Court * Last Day of Contact * Household Information Other Adults Living in Your Residence * Other Children Living in Your Residence * Legal Information Attorney Representing the Child * Legal Custody of Each Child * Physical Custody of Each Child * Previous Visitation Arrangements * Previous Next Your Attorney Information Attorney Name * Attorney Phone * Attorney Address * Emergency Contacts Contact 1 Name * Phone Number * Address * Contact 2 Name * Phone Number * Address * Previous Next Additional Information Ever been convicted of a felony? Yes No Any restraining order preventing contact with others? Yes No Police been contacted to enforce the restraining order Yes No Have charges ever been filed against you or the other party? Yes No Other party ever physically, sexually, or emotionally abused you Yes No Police been called regarding a domestic violence incident Yes No Do you or the other party own weapons Yes No Have your children ever been abused Yes No Ever been involved with children protective services Yes No Has the other party ever stalked you Yes No Do you have any medical problems Yes No Do any of your children have any medical problems Yes No Do your children have any special needs Yes No Have you ever drank alcohol Yes No Has the other party ever drank alcohol Yes No Have you ever used drugs Yes No Has the other party ever used drugs Yes No Have You or the Other Party Ever Utilized Services of Another Supervised Visitation Agency? Yes No Previous Submit
