Today's Date
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MM
DD
YYYY
Are you the custodial parent
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Yes
No
Name of Person Submitting Intake
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First Name
Last Name
Phone of Applicant
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(###)
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Home Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
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Relationship to child/ren
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Custodial Parent / Adult
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Children's Name/s and DOB
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Please List Each child and their DOB
Mother's Name
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First Name
Last Name
Phone
(###)
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####
Email
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Father's Name
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First Name
Last Name
Phone
(###)
###
####
Email
First and Last name
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Emergency Contact
First Name
Last Name
Phone number
(###)
###
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Visit Information
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Please list any details for the visit and or court orders.
If things like taking photos, gifts, and phone calls are not outlined in the court order. It will be up to the discretion of the program Manager and the supervisor.
Approved Court Ordered Visitors
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Please list the names of all people who CAN attend a visit. If there is no court order and this is not outlined, it will be up to the custodial parent who can attend the visit.
Visiting Phase and Purpose of Visit
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Please choose one phase.
Are you able to provide a Court Order for our records?
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Yes
No
There is no order at this time
Known Risks or Any Important Information
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Infections diseases etc. List any court-ordered specifics. If there is no court order please write N/A.
Our fee is $50.00 per hour with a minimum 2-hour call out, and any visits outside our main office will result in a travel fee of $35 per hour. We are a fee-for-service program. If a report for court or lawyer is requested, there is a fee of $50.00 an hour billed at a minimum of two hours. Any court-appointed appearances are billed at $1000.00.
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ALL Payments are due Tuesday before your scheduled weekend visit, or 4 days prior to a weekday visit. You will receive one reminder the day it is due If payment has not been received. If it is not received on time, we will have no choice then to cancel your visit to allow another client to access your time spot. Payments can be made by Email Money Transfer (EMT) information will be provided after your first visit has been booked. **FCI will cancel the visit if payment is not received on time. We recommend payments be made in advance, so this does not happen, as all fees are refundable with a 72-hour cancellation notice. If the child is sick refunds will be approved if a doctor’s note can be provided after the 72-hour mark. Otherwise, the visit will be recorded as a late cancel with no proof of why visit was cancelled. This will be documented as notes and available to both parties. Receipts are available upon request.
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We provide supervision on weekdays and weekends up to 6:00 pm. We may require one-week notice for the first visit. The first visit is an Introduction visit and will be a maximum of two hours (depending on court order). This allows all parties to meet and become comfortable with each other. After the first visit, we will provide supervision for up to 8 hours, providing we can find a supervisor willing to supervise for an extended period.
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A court order is not required. However, we feel it is in everyone's best interest if we have all the information. We will do our best to support the court order, but we cannot enforce them.
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During the visit, a contact note will be written for FCI records. A request can be made for the notes for a fee of $15 per visit note per parent or party (each party is responsible to pay and submit a request for the notes.) We require a minimum not limited to of one week's notice after payment has been received.
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Our main objective is to ensure the well-being of the child(ren) at the visit. We are not interested in the personal details of the different parties involved. The visit will be terminated if anything inappropriate arises during the visit. This would include intoxication, suspected drug use, inappropriate language, activities or discussions, someone who shows up at the visit, which is not on the court order or preapproved by the program manager. These MUST be done at least 24 hrs before the scheduled visit.
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All parties are required to be on time. If you are going to be late, we request you let the facilitator know as soon as possible. We will not make the other party wait more then 20 mins. FCI will not stay longer than the scheduled time. All visits need a minimum of 72 hours' notice to cancel.
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FCI has brought back in some toys and activities, you are welcome to bring other age-appropriate activities you feel your child(ren) may enjoy. If you require some more ideas, please let us know.
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All VISITING parents will be required to enter through the backside door on the south end of the building -No more than 5 mins before your scheduled time. There is parking at the Home Depot or on the street. As long as you refrain from walking and driving past the main entrance. Upon entry, you will be asked to go up the stairs and remain there. You can wave and watch from the big window upstairs and wait near the upstairs elevator door. This is a strict rule. There will be no warnings, and we will no longer book you in for visits if you do not follow. At the end of the visit, goodbyes will be said at the door to the back stairs, and you will leave out the same door you entered in.
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You need to understand photos may be taken during your parenting time (unless otherwise indicated in a court order). Videos or recordings are prohibited. No weapons, animals or pets are permitted. The visiting parent is NOT permitted to administer any medications or Tylenol during a visit. There will be no whispering or attempts to hide a conversation with the child. We will not pass notes or gifts between parents or serve parents with court papers before, during or after a visit. The visit location is not the place for these matters. The bathroom stall door must remain open per our SAS standards if a child needs assistance in a bathroom setting. You understand you are responsible for your child's behavior during the visit. SAS can end the visit if your child's behavior is beyond your control. Our program is a community-based program, and there is a possibility the supervisor may allow you to go outside if the weather permits unless your court order states you are not to leave the building. It is in the best interest to have your child to have some outside fun and not be confined to the indoors.
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All DROP-OFF parents/guardians will enter and exit through the main entrance at the time of the visit EVERYONE is expected to walk directly to their car and leave immediately. We believe all our clients have a right to privacy, as do the children. This is why it is essential to go right after your visit and not stay to talk to your supervisor. If you have any concerns or questions, please address them via email or a phone call. The supervisor will not address these at the visit. ** Any extra supervision time will result in a fee of $5.00 per minute. This includes hanging around the parking lot or staying after to talk to the supervisor or the other visiting party. **
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I have read and understand FCI's guidelines for SAS.
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You are responsible to READ and understand our SAS Program Guidelines. A PDF copy of our guidelines can be downloaded above.
Disclosing Party
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Your Name
First Name
Last Name
Receiving Party/Organiztion: Family Connections Inc.
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Effective Date
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MM
DD
YYYY
Authorization: I,
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First Name
Last Name
hereby authorize Family Connections Inc. to release the above-mentioned information to Family Connections Inc. for the purpose of complying with supervised visits. These may be ordered by court or not.
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Confidentiality: The information disclosed under this agreement shall be kept confidential and used solely for the purpose specified above. The Receiving Party agrees not to disclose the information to any third party without the prior written consent of the Disclosing Party.
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Duration of Authorization: This authorization is valid from the date above until visits have been terminated. I understand that I have the right to revoke this authorization at any time by providing written notice to Family Connections Inc.
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Confidentiality: The information disclosed under this agreement shall be kept confidential and used solely for the purpose specified above. The Receiving Party agrees not to disclose the information to any third party without the prior written consent of the Disclosing Party.
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Digital Signature and agreement.
First Name
Last Name
