Supervised Visitation Custodial Supervised Visitation Custodial For DRC private visitation program About YouYour Name(Required) First Last I am the:(Required)FatherMotherFamily MemberGuardianYour Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Phone(Required)Your Email Address(Required) Email Address Confirm Email Address Availability for Visits:(Required)How often, and for how many hours at a time, would you like to set up visits?(Required)Name of Noncustodial Party/Other Parent(Required) First Last Do you have contact with the noncustodial party?(Required)Indicate the status of your relationship with the other parent:(Required) Divorced Separated Never Married Married No relationship Estimate how many times you've been to court concerning visitation disagreements?Court/Judge Information (if none, write n/a)(Required)Is there an Order of Protection preventing you and the other party from having direct contact with each other?(Required) Active and Ongoing Lapsed or Expired None Do any of the child(ren) have special needs or medical needs? If yes, indicate which child and what the needs are.(Required)Do any of the child(ren) have allergies or dietary restrictions? If yes, indicate which child and what the restrictions are.(Required)What is your understanding of the reason why visits are ordered to be supervised?(Required)The decision for visitation was made by or with assistance from:(Required) Counselor or Mediator You and the other parent Attorney Court / Judge Please describe the current visitation arrangements.(Required)Do you have any concerns, or is there anything else you would like us to know?(Required)CAPTCHA
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