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Step
1
of
4
25%
Screening Form Service
(Required)
Which service are you signing up for?
Supervised Visitation
Safe Exchanges
Case Number
Leave blank if unknown
Name
(Required)
First
Last
Custodial or Non-Custodial?
(Required)
Are you the Custodial OR Non-Custodial Parent?
Non-Custodial
Custodial
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
(Required)
Alternate Phone Number
Email
(Required)
Other Party's Name
What is the Full name of the other party on the case? (Use names listed on Court Order documentation)
First
Last
Other Party's Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Other Party's Phone Number
Other Party's Email*
(Required)
Who referred you?
(Required)
Have you used 101 Visitation Solutions services before?
(Required)
If so, when?
Who is the Family Court Services Counselor OR Private Mediator?
Indicate NA if not Applicable
FCS Mediator OR Private Mediator's Phone Number
Do you have an attorney?
Please provide their name, address, phone number and email if available.
Does the other party have an attorney?
Please provide the attorney's name, address, phone number and email if available.
Is there a Court Appointed Evaluator?
If yes, please provide name, address, phone number and email if available. Indicate "NA" if Not Applicable.
Is there a Court appointed Therapist?
If so, indicate who's therapist it is, their name, address, phone number and email if available. Indicate "NA" if Not Applicable
Children (NAME, DATE OF BIRTH, SEX)
(Required)
Please provide the ALL children's full name (as they appear in court order documentation), their dates of birth and the sex of each child.
Is there an attorney that represents the child(ren)? AKA Minor's Counsel
Provide their name, phone number and email if available. Indicate "NA" if Not Applicable.
How long has it been since the children had contact with the Non-Custodial parent?
(Required)
Children (NAME, DATE OF BIRTH, SEX)
(Required)
Please provide the ALL children's full name (as they appear in court order documentation), their dates of birth and the sex of each child.
Why is supervised visitation recommended in this situation?
(Required)
For example: Due to a Restraining Order, due to child abuse, mental illness, etc.
How many hours per week are ordered?
(Required)
Has there been a previous order for supervised visitation?
(Required)
If yes, where did you receive services and the dates of services:
Next Court Date?
MM slash DD slash YYYY
Next Mediation Date?
MM slash DD slash YYYY
Is there any risk of flight/abduction on the part of either parent?
(Required)
Yes
No
Are there any Restraining Orders in effect?
(Required)
Yes
No
If yes to above question: Against whom, why, and expiration date?
Is there a history or current concern about Domestic Violence?
(Required)
Yes
No
If there a history or current concern about Child Abuse (physical or sexual)?
(Required)
Yes
No
If yes to above question: Indicate what type of abuse.
Is there a history or current concern about Alcohol or Drug Abuse?
(Required)
Yes
No
If yes to above question: Indicate the type of alcohol or drug abuse.
Is there an order for alcohol or drug assessment/testing?
(Required)
Yes
No
Do you smoke cigarettes around the child(ren)?
(Required)
Yes
No
Please indicate if there are any legal issues pending that are related to the case.
(Required)
Indicate "NA" if no legal issues pending.
Please indicate if the child(ren) have any medical conditions, food allergies, or special needs that we should be aware of.
(Required)
Indicate "NA" if Not Applicable