Safe Connection Intake Form

Family Information

This information is kept confidential and must be completed by both parties before the orientation process begins.

Today's Date(Required)

How did you hear about us?

Primary reason for referral(Required)

Domestic Violence

Stalking

Sexual Assault

Other

.Type of Service Requested(Required)

Supervised Visitation

Supervised Exchanges

First Name and Middle Name(Required)

Last Name(Required)

Preferred Name

Phone number(Required)

Email Addreses(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Language Spoken(Required)

Name of other parent (First and Last)(Required)

Names and birthdates of Children(Required)

Has there been court involvement regarding custody and/or visitation? (if yes, please provide details)

Date of Next Court Appearance Regarding Custody and Visitation

Restraining / Protective Order?(Required)

Yes - Current

Not Currently - previous protection order

Not aware that there has ever been a restraining or protective order issued

Restrained Party's Name

Protected Party's Name

Restrictions

CSC actively works with families to determine how to safely meet the needs of children and protected parents. We will always work with families to create services that fit safety concerns, however, the program reserves the right to make final decisions.

Should restrictions on third parties attending visitations be considered by the program for safety reasons? If so, please identify whom?

Should other restrictions or guidelines be considered by the program?

Please provide any other narrative details regarding why supervised visitation services have been recommended or agreed upon:

Availability

We currently offer supervised parenting time on Saturday or Sunday with three different time blocks.

Please mark all scheduling options that you are available for.(Required)

Saturday

Sunday

Morning

Early Afternoon

Late Afternoon