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!
