SERVICE REQUESTED

Supervised Monitoring

Neutral Exchange

CWOP (CPS only)

Therapeutic Visitation

Who is REFERRING?

Judge

CASA

CPS

Guardian ad Litem

Therapist

Other

Name

First Name

Last Name

Phone

(###)

###

####

These are the services UVC

o Supervised monitoring ▪ On-site visitation is observational, where the monitor sees and listens to all interactions between parents and children. ▪ Off-site visitation through UVC will be line-of-sight, which means that monitors will only do visual observation, without recording conversation. o With neutral exchange UVC provides a child-friendly environment and a monitor to help keep the peace and resolve conflict during custody exchange. o With CWOP (Children Without Placement) services UVC offers monitoring for the temporary emergency care of children until placement can be secured. o Therapeutic visitation, such as the Nurtured Parenting Program, combines observation visitation with parenting training.

COURT INFORMATION:

Court

Judge

County of Court

State of Court

Referral Date

Cause Number

WHO SHOULD RECEIVE VISITATION NOTES?

Note: UVC will automatically send notes to guardian ad litem (if any) and CPS. UVC will charge for requested notes.

Persons Receiving Notes

Phone

ATTORNEY FOR VISITING PARENT/PERSON

Attorney Name

Phone

Attorney Address

ATTORNEY FOR CUSTODIAL PARENT/PERSON

Attorney Name

Phone

GUARDIAN AD LITEM

Attorney Name

Phone

Attorney Address

ATTORNEY FOR CUSTODIAL PARENT/PERSON

CHILD'S NAME, GENDER, DATE OF BIRITH, AGE, CUSTODIAL/FOSTER. PARENT OR PLACEMENT, CITY WHERE CHILD LIVES

Please list the child(ren)'s name(s) and gender(s) as they appear on their current birth certificate(s). If they prefer to be called a different name and identify/present with a different gender, please add information below.

VISITING PARENT/PERSON

Name

Date of Birth

Home Address

Mailing Address

Cellphone

Home phone

Work phone

EMAIL – Required for scheduling and communication

CUSTODIAL PARENT/FOSTER PARENT/PLACEMENT PERSON

Name

Date of Birth

Phone

Home Address

Spouse's Name

Spouse's Phone

What is your Role?

Custodial Parent

Foster Parent

Placement

SECOND CUSTODIAL PARENT/FOSTER PARENT/PLACEMENT PERSON

(If more than two, use separate sheet.)

Name

Date of Birth

Phone

Home Address

Spouse's Name

Spouse's Phone

What is your Role?

Custodial Parent

Foster Parent

Placement

VISIT DETAILS

Other Persons Allowed in Visit

Name

Relationship

Length of Visit

Frequency of Visit

Requested Schedule and Times

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

Requested Visit Location

(Visit locations must be pre-approved by UVC)

May Visit Take Place Virtually?

Phone

Video

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?

SERVICES AND WHO IS RESPONSIBLE? Note that the following 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

Intake

Visiting Parent

Custodial Parent

Split Evenly

Other

Supervised Visitation

Visiting Parent

Custodial Parent

Split Evenly

Other

Therapeutic Visitation

Visiting Parent

Custodial Parent

Split Evenly

Other

Court Retainer

Visiting Parent

Custodial Parent

Split Evenly

Other

Testimony Hourly Rate

Visiting Parent

Custodial Parent

Split Evenly

Other

Reports

Visiting Parent

Custodial Parent

Split Evenly

Other

Neutral Exchange

Visiting Parent

Custodial Parent

Split Evenly

Other

Interpreter

Visiting Parent

Custodial Parent

Split Evenly

Other

Consultations

(attorney, therapist)

Visiting Parent

Custodial Parent

Split Evenly

Other

CONCERNS ABOUT VISITING CHILD(REN)

Is there a history of any of the following behaviors and please indicate which minor child/ren

Lying, whispering, hiding, angry outbursts, anxiety, unresponsive silence, physical aggression, substance abuse, accidental wetting or soiling, allergies, dietary restrictions, or medical conditions that may affect visit, and other (please explain).

Explain “Other” if checked

Reason for supervised visitation:

Domestic Violence

Physical Abuse

Sexual Abuse

Neglect

Reunification

Other

CONCERNS ABOUT NON-CUSTODIAL PARENT/PERSON

Any concerns that we should know about (temperament, excessive phone calls, unreasonable rules for UVC or visiting parent, etc.)?

FILL IN IF THE PURPOSE OF VISITATION IS REUNIFICATION

WHEN WAS THE LAST TIME CHILD AND PARENT SAW ONE ANOTHER?

ANY CURRENT VISITATION SCHEDULE

SUGGESTED STAIR-STEP SCHEDULE IN SUPPORT OF REUNIFICATION

1 visit of 2 hours every week for 3 weeks, followed by 2 visits of 2 hours every week for 3 weeks, followed by 3 visits of 3 hours every week for 3 weeks

Notes

Notes: • The referring person shall have the visiting and custodial parents fill in the intake/application forms found on UVC’s website. The referring person may not complete the intake/application forms–the clients must complete them. • UVC understands Texas Standard Possession Order, but to serve many families who have the exact same assigned visitation dates, we offer alternative weekends and other times, to ensure that all parents get the amount of visiting time they are ordered. • Unity Visitation Center does not provide counseling during visitation, except during therapeutic visitation. • If you have any additional questions, please visit our website at www.uvctexas.org and/or feel free to contact our Executive Director at uvctexas@gmail.com. • Please send the completed form to uvctexas@gmail.com.

Referral Form for Supervised Visitation Services

SERVICE REQUEST