Family Services

Supervised Visitation / Parenting Time

Time with your kids matters — and when a court or family situation requires that time to be monitored, it should still feel like parenting, not like an inspection. Hope Council’s Parenting Time program provides monitored visitation in a setting built for safety and consistency, with hours that work for real families, including evenings and weekends. No referral required.

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PART 1 · My Information

Parent role*
You must select one of the following:*

OTHER PARENT

Please provide this information in order to assist in scheduling:

CHILD(REN)

Add a block for each child. Attach additional sheets if more space is needed.
Sex
Add up to 10 repeated fields.

ATTORNEYS OR SOCIAL WORKERS INVOLVED

List anyone — an attorney, Guardian ad Litem, or social worker — involved in the case.
Person
Add up to 10 repeated fields.

PART 2 · RELEASE OF INFORMATION

I hereby request and authorize the Supervised Visitation Program of the Hope Council on Alcohol & Other Drug Abuse to receive and disclose information and records to the Guardian ad Litem, both parents' attorneys of record, and the Court, as ordered. This authorization includes the exchange of information necessary for the administration, coordination, and reporting of supervised visitation services, including attendance, compliance, scheduling, observations, and other information relevant to the supervised visitation case, as permitted by applicable law.

TIME PERIOD & EXPIRATION

This authorization expires*

YOUR RIGHTS — PLEASE ACKNOWLEDGE

This authorization is voluntary*
I have the right to receive a copy of this authorization.*
I may withdraw this authorization at any time by written notice to Hope Council; the cancellation takes effect when received and does not apply to disclosures already made.*

SIGNATURE

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