Unity Visitation Center Intake Form PARENT'S NAME * First Name Last Name DATE OF BIRTH * MM DD YYYY I am the * Custodial Parent Visiting Parent Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone Number * (###) ### #### Home Number * (###) ### #### Work Number * (###) ### #### MAY WE LEAVE A MESSAGE? * CELL PHONE NUMBER HOME PHONE NUMBER WORK PHONE NUMBER BEST NUMBER TO REACH YOU? * CELL PHONE NUMBER HOME PHONE NUMBER WORK PHONE NUMBER EMAIL ADDRESS - Required for scheduling and communication * OCCUPATION EMPLOYER * SUPERVISOR EMPLOYER ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country WORK DAYS AND HOURS AVAILABLE FOR VISIT? * MONDAYS TUESDAYS WEDNESDAYS THURSDAYS FRIDAYS SATURDAYS SUNDAYS OTHER INFO ABOUT YOUR AVAILABILITY: CURRENT VISITATION SCHEDULE (if any): PREVIOUS CLIENT OF UVC? YES NO DATE OF SERVICE CHILD'S NAME(S) * PARENT'S HEALTH - DESCRIBE YOUR MEDICAL CONDITIONS THAT UVC STAFF SHOULD BE AWARE OF: * MENTAL HEALTH HISTORY OR CONDITIONS: OTHER CONDITIONS OR IMPAIRMENTS: YOUR CHILDREN'S HEALTH - DESCRIBE YOUR CHILD'S MEDICAL CONDITIONS THAT UVC STAFF SHOULD BE AWARE OF: * IS YOUR CHILD SEEING A THERAPIST/COUNSELOR? * YES NO CHILD'S ALLERGIES, INCLUDING SEASONAL: CHILD'S PRESCRIPTION DRUGS: SUBSTANCE ABUSE HISTORY ALCOHOL ABUSE * BY YOU (YES) BY YOU (NO) BY OTHER PARENT (YES) BY OTHER PARENT (NO) BY OTHER PARENT (I DON'T KNOW) STREET DRUGS * BY YOU (YES) BY YOU (NO) BY OTHER PARENT (YES) BY OTHER PARENT (NO) BY OTHER PARENT (I DON'T KNOW) PRESCRIPTION DRUGS * BY YOU (YES) BY YOU (NO) BY OTHER PARENT (YES) BY OTHER PARENT (NO) BY OTHER PARENT (I DON'T KNOW) DO YOU BELIEVE THERE IS A CURRENT PROBLEM WITH DRUGS OR ALCOHOL? * BY YOU (YES) BY YOU (NO) BY OTHER PARENT (YES) BY OTHER PARENT (NO) BY OTHER PARENT (I DON'T KNOW) BEHAVIORS OBSERVED WHILE UNDER THE INFLUENCE: TREATMENT HISTORY: SOBRIETY HISTORY: CASE INFORMATION JUDGE COURT COUNTY OF DIVORCE OR DECREE CASE NUMBER YOUR DIVORCE ATTORNEY ATTORNEY NAME ATTORNEY ADDRESS ATTORNEY PHONE ATTORNEY EMAIL CHILDREN LISTED IN COURT ORDER FOR VISITATION: CHILD'S NAME, GENDER, DATE OF BRITH, AGE * John, M, April 8 2022, 3 ATTORNEY HELPING YOU WITH VISITATION ON THIS CASE ATTORNEY NAME ATTORNEY ADDRESS ATTORNEY PHONE ATTORNEY EMAIL HAS THERE EVER BEEN ANY FAMILY VIOLENCE? * YES NO DESCRIBE * ESTIMATE HOW MANY TIMES YOU HAVE BEEN TO COURT CONCERNING VISITATION DISAGREEMENTS: * HAS POLICE OR LAW ENFORCEMENT EVERY BEEN CALLED DURING A VISIT OR EXCHANGE? DESCRIBE: * HAS CHILD PROTECTIVE SERVICES (CPS) OR DEPARTMENT OF FAMILY PROTECTIVE SERVICES (DFPS) BEEN INVOLVED WITH YOU OR THE OTHER PARENT OR IS THERE AN OPEN CASE WITH CPS/DFPS? * YES NO DESCRIBE * CASE WORKER INFORMATION CASE WORKER NAME: CASE WORKER NAME: CASE WORKER PHONE: CASE WORKER EMAIL: CASE WORKER ADDRESS: Have you and /or the other party ever been arrested? * YES (ME) NO (ME) YES (OTHER PARTY) NO (OTHER PARTY) Does Not Apply DESCRIBE * Is there a restraining order preventing you and the other party from having direct contact with each other? * YES NO DESCRIBE * A COPY MUST BE SUPPLIED How many times have the police been contacted to enforce the restraining order? Is there now or has there ever been a restraining order, protective order, or trespass warrant in effect against you, the other parent, or anyone else in the household? YES NO DESCRIBE DESCRIBE Have you and /or the other party ever been convicted of a felony or misdemeanor? YES (ME) NO (ME) YES (OTHER PARTY) NO (OTHER PARTY) DOES NOT APPLY Have you ever been accused, charged, or convicted of sexual assault, indecency, injury, endangerment or neglect of a child? If yes, please explain: Is there any history of abuse by the other party toward you? YES NO Physical (slapping, kicking, burning, destroying/throwing objects) YES NO Sexual (raping, forcing, threatening sex, sex in presence of others) YES NO Emotional (humiliating, name-calling, isolating, threatening to hurt or kill) YES NO Has there ever been a physical altercation between you and any other person that is in contact with the child? YES NO Have there ever been charges filed against you or the other party for physical abuse? * YES (ME) NO (ME) YES (OTHER PARTY) NO (OTHER PARTY) Does Not Apply Do you or the other party own any weapons? * YES (ME) NO (ME) YES (OTHER PARTY) NO (OTHER PARTY) Does Not Apply DESCRIBE Have these weapons ever been used or threatened to be used in a dispute? YES NO DESCRIBE Have you or the other party assaulted or made threats to police, therapist, DHS or court official? * YES (ME) NO (ME) YES (OTHER PARTY) NO (OTHER PARTY) Does Not Apply DESCRIBE Has a child witnessed abuse? YES NO Which child and what did they see or experience? Has your child intervened? YES NO DESCRIBE Have your children been abused (hit, hurt, threatened)? YES NO Types of Abuse they experienced: PHYSICAL SEXUAL EMOTIONAL Describe which child experienced which abuse: Thank you! Custody and Visitation Arrangements If there are different arrangements for different child(ren), please fill out a separate sheet for each visitation arrangement. PARENT'S NAME * First Name Last Name DATE OF BIRTH MM DD YYYY CHILD(REN) INVOLVED IN THIS VISITATION ARRANGEMENT CHILD'S NAME * CHILD'S NAME, GENDER, DATE OF BIRTH, AGE * John, M, April 5, 2022, 3yo WHO PRESENTLY HAS LEGAL CUSTODY? * Guardian Father Mother Joint DHS Not Determined WHAT REASONS DO YOU THINK YOU WERE REFERRED TO UVC? (MARK ALL THAT APPLY) * Domestic violence allegations or history of violence Sexual abuse allegations Children witnessed abuse Inconsistency or unreliability Substance abuse history Lack of access/alienation of the children Mental health history or Instability Poor parenting Skills Child abuse allegations Abduction risk (threatened or attempted) Neglect or threat to the child or Other WHO PRESENTLY HAS PHYSICAL CUSTODY? * Guardian Father Mother Joint DHS Not Determined HAVE YOU INFORMED YOUR CHILD OF THE COURT ORDER AND WHY YOU ARE COMING TO UVC? * YES NO TOO YOUNG TO UNDERSTAND WHAT DO YOU EXPECT YOUR CHILD’S REACTION WILL BE ABOUT COMING TO UVC? (HAPPY? SAD? SCARED? ANGRY? SHY? ETC.) WHAT CAN WE DO TO MAKE THIS A GOOD EXPERIENCE FOR THEM? * PLEASE LIST ANY OTHER CONCERNS OR INFO THAT UVC SHOULD KNOW * Custodial parent: Please review with your child the handout: How to Prepare your Children for Visitation. Thank you! YOUR ANSWERS MAY HELP US SERVE THE COMMUNITY BETTER PARENT’S NAME (optional) First Name Last Name DATE OF BIRTH (optional) MM DD YYYY LEVEL OF EDUCATION RELIGIOUS/SPIRITUAL BELIEFS: HOBBIES: ETHNICITIES (pick all that apply) American Indian or Alaska Native Asian American/ Pacific Islander Black or African American Hispanic Multi-Ethnic White Other INCOME $10,000-19,999 $20,000-29,999 $30,000-39,999 $40,000-49,999 $50,000 and above $10,000-19,999 YOUR ECONOMIC STATUS Have you recently experienced an economic disadvantage? YES NO EXPLAIN Thank you! PARENTAL AGREEMENT PATIEN'TS NAME * First Name Last Name DATE OF BIRTH * MM DD YYYY I have read and understood the Unity Visitation Center “Intake Form,” and to the best of my knowledge, I have filled it out accurately and completely. I have read and understood the Unity Visitation Center “Supervised Visitation and Exchange Procedures – for Parents,” and I agree to abide by them as long as I am a client of Unity Visitation Center. I agree to participate in supervised visitation, which includes following policies and rules to create a safe environment for parent-child interaction. I will follow these rules and if I am not certain of a rule, I will seek clarification before acting upon it. I recognize that all interactions are written down and reported to the Court. These are observations of my behavior without judgment or prejudice. I certify that the information given above is true and complete and I understand that misrepresentation and/or withholding of information will result in the rejection of this application or my dismissal as a client if discovered after service begins. I understand the court will be notified of this dismissal and that this may affect the visitation or custody of my child. I understand that UVC can make no promises or guarantees relating to visitation or court matters, and that my client status may be suspended any time that I or any part of my family/friends become unsafe for the facilities and/or staff of UVC. I understand that any termination as a client will be documented and that this documentation may be presented to the court. I expressly understand and agree that Unity Visitation Center and its agents will not be liable for any direct, indirect, incident, special, consequential or exemplary damages, including without limitation, damages for loss of profits, goodwill, use, data or intangible losses. I acknowledge that this contract is not subject to renegotiation. I understand that Unity Visitation Center reserves the right to change policies or procedures at any time and to change guidelines and plans on a case-by-case basis. * PARENT'S PRINTED NAME: SIGNATURE- 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 Thank you!
