Guardian Intake | Child Safety First

Custodial parent or guardian full legal name

Email address

Phone number

Date completing this form

Preferred visit location

Visiting parent full name, relationship to the child, phone number, and email address

Is contact between you and the visiting parent restricted?

Is supervised visitation required by a current court order?

Are protective, no-contact, criminal, custody, or safety orders currently in effect?

Requested visit format

Requested visit frequency

Child information: legal names, preferred names, dates of birth, and ages

Court, county, case number, and all visitation or exchange restrictions

Visit plan: availability, transportation and exchange details, emergency contact, and every other person approved to attend with relationship to each child (write None if no one else is approved)

Child health, allergies, medication instructions, routines, safety concerns, and prohibited locations, people, discussion topics, items, or conduct

Payment responsibility: name, role, billing phone/email, and court or agency details

I will not photograph, audio record, video record, livestream, or post images or recordings of Child Safety First staff without written permission.

I understand Child Safety First does not control and is not responsible for content independently posted, shared, or distributed online.

I certify that this information is complete and accurate to the best of my knowledge.

Child Safety First use only - approved hourly rate and effective date

Supervised Visitation - Custodial Parent and Guardian Intake