Guardian Intake | Child Safety First

Custodial Parent/Guardian/Agency Service Agreement

Date of form completion

Each child's legal name, preferred name, age, and date of birth

Custodial Parent/Guardian/Agency Phone This field is required Please enter a valid phone number

Email: This field is required Please enter a valid email address

Authorization for Supervised Visitation-I confirm that I am the child's custodial parent, legal guardian, or authorized agency representative and have the legal authority or agency authorization necessary to arrange the requested visitation services. I agree to provide applicable court orders, agency instructions, and relevant safety restrictions before services begin. I understand that CSF cannot independently modify a court order or authorize visitation outside the approved arrangement. Acknowledgment: I certify that I have the necessary authority to request these services and will provide accurate, current authorization documents.

Name of primary caretaker, if same type n/a

Primary Cartaker's phone number (if same type n/a)

Primary Caretaker's email

Emergency contact name and phone number

Are there any current court orders that govern custody, visitation, communication, or contact involving the child(ren)?

Child's Medical, Developmental, and Emotional Needs-I agree to disclose information reasonably necessary for CSF to supervise the child safely, including relevant medical conditions, allergies, developmental or communication needs, emotional triggers, and necessary accommodations. I understand that CSF does not administer medication and that any necessary medical arrangements must be established before visitation. I will notify CSF of material changes affecting the child(ren)'s safety or participation.

Please explain any emotional or behavioral triggers and calming strategies

Please explain the child(ren)'s comfort items, feeding, toileting, and other age-appropriate care needs

Have there been threats of weapons, abduction, or unauthorized-person concerns

Are there any concerns about the visiting parent's ability to participate safely

Please describe the child(ren)'s Child's willingness, fear, or reluctance concerning contact

Requested visit format

Requested frequency, duration, and availability

Approved and/or Prohibited Participants and Visitors-Please list person approved to particpate, and people prohibited and the relation to the child(ren)

Is there a history or concerns involving violence, threats, stalking, harassment, or coercive control

Is the visiting parent permitted to provide snacks, drinks. If so, are there any restrictions? If the visiting parent is not permitted or restricted explain below

Do you authorize the visiting parent to provide gifts during supervised visitation? If so, are there any restrictions?

Who is responsible for payment and applicable fees

Scheduling and Timely Arrival-The custodial parent, guardian, or authorized agency representative is responsible for ensuring the child arrives at the designated location at the scheduled time, unless transportation is assigned to another party. If the child arrives more than 10 minutes after the scheduled arrival time, the visit may be canceled. When the delay is attributable to the guardian or responsible agency, the full scheduled visitation fee may apply under the service agreement.

Cancellation and No-Show Policy-A minimum of 24 hours' notice is required to cancel or reschedule a scheduled visit. Cancellations made with less than 24 hours' notice, including failure to bring the child to a confirmed visit, will result in a charge equal to 100% of the scheduled visitation fee, unless CSF approves an exception or a separate agency agreement provides otherwise. Acknowledgment: I understand the cancellation requirements and the applicable financial responsibility.

I understand, and agree

Inclement Weather and Emergency -The safety of children, families, and staff takes priority over scheduled visitation. CSF reserves the right to cancel, postpone, or reschedule visits when weather conditions, road closures, power outages, facility closures, or other emergencies create unsafe conditions. When CSF cancels a visit because of safety conditions, no cancellation fee will be assessed. Participants who believe travel conditions are unsafe must notify CSF as soon as possible, preferably before the scheduled visit. CSF will review the circumstances and determine whether the visit should be rescheduled without penalty. CSF is not responsible for travel expenses, lost wages, or other incidental costs resulting from weather-related cancellations-Closures

I understand and acknowledge

Alcohol, Drugs, and Impairment-Participants must not attend supervised visitation while impaired by alcohol, illegal drugs, or any substance that compromises their ability to participate safely. Alcohol, illegal drugs, and unauthorized controlled substances are prohibited during visits. CSF may deny participation or terminate a visit when observable behavior raises a reasonable concern regarding impairment or immediate safety. Any court-ordered or agency-required substance testing or monitoring remains the responsibility of the designated testing provider or agency unless otherwise expressly agreed in writing.

Photographs, Video, and Social Media Authorization-Please indicate whether you authorize the visiting parent to take pictures/video of the child(ren)?

Emergency Medical Response-I authorize CSF to contact emergency services and take reasonable steps to obtain appropriate assistance if the child experiences an apparent medical or safety emergency during supervised visitation. I understand that CSF will make reasonable efforts to notify the guardian and other authorized contacts as circumstances permit.

Documentation and Confidentiality-I understand that CSF maintains professional records of supervised visitation services, including attendance, observations, relevant communications, and incidents. I understand that records may be disclosed when required by law, valid legal process, mandatory reporting requirements, or an applicable authorization. I understand that CSF provides objective supervision and documentation and does not guarantee a particular outcome in custody or other legal proceedings.

Changes in Custody, Safety, or Legal Circumstances-I agree to promptly notify CSF of any changes involving custody, protective orders, visitation authorization, approved participants, safety concerns, or other circumstances affecting the child. I understand that CSF may require updated documentation before continuing services.

I understand and agree

Responsibility for the Actions or Inactions of Others-Child Safety First, LLC (CSF) is committed to providing professional supervised visitation services in accordance with established policies, applicable court orders, and reasonable safety procedures. CSF is not responsible for the independent actions, inactions, decisions, misconduct, or failure to comply with established requirements by parents, guardians, family members, agency representatives, or other third parties outside CSF's control. Each individual remains responsible for their own conduct, decisions, and compliance with applicable court orders, visitation requirements, and safety procedures. CSF cannot guarantee the conduct, cooperation, or compliance of any participating individual. Nothing in this provision relieves CSF of its own legal duties or responsibility for its own negligence or misconduct.

Photography, Video, and Audio Recording of CSF Personnel-To protect the privacy, safety, and professional integrity of Child Safety First, LLC (CSF), custodial parents, guardians, agency representatives, and other individuals involved in supervised visitation are prohibited from photographing, video recording, audio recording, livestreaming, or otherwise capturing images or recordings of CSF personnel without prior written authorization from CSF. This restriction also applies to the publication, distribution, or posting of unauthorized images or recordings of CSF personnel on social media or other platforms. Violations may result in suspension or termination of services, subject to applicable court orders, contractual obligations, and law. Required Acknowledgment: I understand and agree that I will not photograph, video record, audio record, or otherwise record CSF personnel without prior written authorization, except as permitted by applicable law.

Please review the following policies carefully. These policies establish expectations for participation in supervised visitation services provided by Child Safety First, LLC (CSF). All participants are expected to comply with applicable court orders, approved visitation plans, and CSF safety procedures.

Guardian / Agency Acknowledgment and Electronic Signature-Guardian / Agency Acknowledgment and Electronic Signature By typing my name and submitting this form, I acknowledge that: I have reviewed and understand the policies applicable to the custodial parent, guardian, or referring agency. I understand the 10-minute arrival rule and 24-hour cancellation policy. I understand the financial obligations applicable to the party responsible for payment. I have provided accurate information regarding the child's needs, authorized participants, and relevant restrictions. I understand the policies governing photographs, recordings, and social media. I agree to notify CSF of changes affecting the child's safety or visitation authorization. I confirm that I am authorized to complete this form on behalf of the child or referring agency.

Custodial Parent/Guardian/Agency Service Agreement

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