Agreement Form between Parents about Supervised Visits through Unity Visitation Center CUSTODIAL PARENT, LEGAL GUARDIAN, OR FOSTER PARENT’S NAME * First Name Last Name Date of Birth * MM DD YYYY Visiting Parent Name: * Date of Birth * MM DD YYYY CHILD(REN) WHO WILL PARTICIPATE IN VISITATION: Child's Name Date of Birth * MM DD YYYY Resides with Child's Name Date of Birth * MM DD YYYY Resides with Child's Name Date of Birth * MM DD YYYY Resides with Child's Name Date of Birth * MM DD YYYY Resides with Child's Name Date of Birth * MM DD YYYY Resides with Child's Name Date of Birth * MM DD YYYY Resides with RESTRICTIONS ON VISITATION: OTHER PERSONS ALLOWED IN VISIT Name | Relationship Length of Visits 1 hour 2 hours Other Frequency of Visits Weekly Twice a Month Other Requested Schedule and Times Weekdays After School Mornings Evenings Weekends Other WHAT LANGUAGE WILL BE SPOKEN BY FAMILY? Note: Language must be spoken by monitor, or family must pay interpreter fee. MAY VISIT/EXCHANGE TAKE PLACE OFFSITE FROM UVC? YES NO REQUESTED VISIT LOCATION: (Visit locations must be pre-approved by UVC) MAY VISIT TAKE PLACE VIRTUALLY? Phone Video No PAYMENT Is one party responsible for all payments? Pays for all services: Visiting Parent Custodial Parent Split Evenly Other: ...Or are various parties responsible for each payment type? Intake * Who is Responsibe? Visiting parent Custodial parent Split evenly Other Supervised Visitation Who is Responsibe? Visiting parent Custodial parent Split evenly Other Therapeutic Visitation Who is Responsibe? Visiting parent Custodial parent Split evenly Other Court Retainer Who is Responsibe? Visiting parent Custodial parent Split evenly Other Testimony Hourly Rate Who is Responsibe? Visiting parent Custodial parent Split evenly Other Reports Who is Responsibe? Visiting parent Custodial parent Split evenly Other Neutral Exchange Who is Responsibe? Visiting parent Custodial parent Split evenly Other Interpreter Who is Responsibe? Visiting parent Custodial parent Split evenly Other Consultations (attorney, therapist) Who is Responsibe? Visiting parent Custodial parent Split evenly Other Note that the following fees are the responsibility of the person who did not follow procedures, no matter who would normally pay for a service: • No show or late fee • Less than 48-hour cancellation/reschedule • Termination of a meeting by UVC due to parent not following UVC procedure I agree to these terms of this informal visitation arrangement, and believe it is in the best interest of the child(ren). I agree to follow UVC procedures. Start Date MM DD YYYY End Date MM DD YYYY Custodial Parent’s name – please print: * INITIALS By adding your initials below, you confirm that all information provided is true and accurate to the best of your knowledge. Your initials serve as your signature, indicating that you agree to the terms, policies, and cost of services of UVC and consent to proceed with supervised visitation services. Date MM DD YYYY Custodial Parent’s witness – please print: INITIALS By adding your initials below, you confirm that all information provided is true and accurate to the best of your knowledge. Your initials serve as your signature, indicating that you agree to the terms, policies, and cost of services of UVC and consent to proceed with supervised visitation services. Date MM DD YYYY Visiting Parent’s Name – please print: INITIALS By adding your initials below, you confirm that all information provided is true and accurate to the best of your knowledge. Your initials serve as your signature, indicating that you agree to the terms, policies, and cost of services of UVC and consent to proceed with supervised visitation services. Date MM DD YYYY Visiting Parent’s Witness – please print: INITIALS By adding your initials below, you confirm that all information provided is true and accurate to the best of your knowledge. Your initials serve as your signature, indicating that you agree to the terms, policies, and cost of services of UVC and consent to proceed with supervised visitation services. Date MM DD YYYY UVC witness – please print: Thank you!
