Fairfield County Visitation Center Referral Form Visitation Plan (Fillable)

Court Location Case Number Referral Source Reason for Referral Person Completing Form Date Phone Number

Service Requested

Parenting Time Supervised Visits Monitored Exchanges

Residential Parent Name Residential Parent Relationship Residential Parent Address Residential Parent City State Zip Code Residential Parent Race Ethnicity Residential Parent Home Telephone Number Residential Parent Cell Number Residential Parent Attorney Number Non Residential Parent Name Non Residential Parent Relationship Non Residential Parent Address Non Residential Parent City State Zip Code Non Residential Parent Race Ethnicity Non Residential Parent Home Telephone Number Non Residential Parent Cell Number Non Residential Parent Attorney Number Case History Expectations of Visiting Party Child 1 Name Child 1 Age Date of Birth Child 1 Address Child 1 City State Zip Code Child 2 Name Child 2 Age Date of Birth Child 2 Address Child 2 City State Zip Code Child 3 Name Child 3 Age Date of Birth Child 3 Address Child 3 City State Zip Code

Special Problems Concerns to watch for

Family Violence Screening History of Domestic Violence

History of Domestic Violence Yes History of Domestic Violence No

Family Violence Screening Prior arrest including weapons

Prior arrest including weapons Yes Prior arrest including weapons No

Family Violence Screening Protective Order Restraining Order

Protective Order Restraining Order Yes Protective Order Restraining Order No

Family Violence Screening Prior arrest involving Domestic Violence

Prior arrest involving Domestic Violence Yes Prior arrest involving Domestic Violence No

Marital Status

Never married Married Separated Divorced

Child Protective Services Involvement

Child Protective Services Involvement Yes Child Protective Services Involvement No