Visiting Parent Intake | Child Safety First

Visiting parent full legal name

Email address

Phone number

Date completing this form

Preferred visit location

Custodial parent or guardian name, relationship, phone number, and email address

Is contact with the custodial parent or guardian 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

Availability, transportation plan, emergency contact, and other authorized attendees

Safety, health, food, medication, photography, recording, and accommodation information

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

I agree to surrender all vehicle keys to the Child Safety First supervisor upon arrival.

I agree to follow all court orders, safety plans, scheduling rules, and supervisor directions.

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