Release/Exchange of Client Information Consent Form Your Name * First Name Last Name Date of Birth MM DD YYYY Other Parent's Name * First Name Last Name Date of Birth MM DD YYYY CHILD(REN) WHO WILL PARTICIPATE IN VISITATION: CHILD(REN) WHO WILL PARTICIPATE IN VISITATION: * Child's name, Date of Birth, Age, Resides with PARTIES WITH WHOM UNITY VISITATION CENTER SHALL EXCHANGE INFORMATION (MANDATORY) • Unity Visitation Center, Inc. Supervised Visitation & Monitored Exchange Center • County District Courts, Court that ordered Visitation/Exchange, Child Support Court, etc. • Department of Family Protective Services • Guardian ad Litem (child’s attorney) • Court Appointed Mediator (if applicable) • Other (to be determined by UVC – for example, CASA – Court Appointed Special Advocate) Thank you!
