Intake For Supervised Visitation Electronic Form

INTAKE FOR SUPERVISED VISITATION

Fill Forms out below or Download the file, fill it out and upload it here.

Step One:

Section Two

Step Two: Supervised Visitation Agreement

Your visits are scheduled based on court order, or other agreements including the cooperation of your Dependency Case Manage if you have one. This is to help provide structure and guarantee the most meaningful visits for you and your family. The program is committed to assuring that scheduling occurs in compliance with your orders and that you are able to take full advantage of your family time together.

All visitors must commit to the following procedures:
1. Visits must be on time. I understand that visits will be canceled if late more than 15 (fifteen) minutes. If I am more than 15 minutes late, I may need to pay the Toby Center for the session even if the session will be cancelled.
2. I agree to contact the appropriate Toby Center Regional Office or my Visitation Monitor at least 24 hours before a visit if I cannot attend. I will be liable to pay the Toby Center for this missed visit before I may reschedule the next visitation session.
3. I understand that I will be removed from the visitation schedule for three consecutive no shows and that unattended visits without adequate notice will be documented as no show.

By checking here, I confirm and I understand the cause for additional payment due to inconveniencing of all parties including my child(ren), their other parent, and the Toby Center.

The program’s first priority is the safety and comfort of child visitors. We are committed to trauma informed care which means that no one will experience painful or disturbing events while visiting. It is important that your child recognize the visitation center as a safe place for you to have the most meaningful visits possible.
All visitors must agree to the following policies:
4. I agree to only visit with my children where the Toby Center monitor has directed. Encounters with the other parent or related parties in the parking lot, lobby, etc. are not allowed. The Toby Center staff may call the nearest police or sheriff’s department if there is any altercation, argument and inappropriate behavior.

By checking here I understand the safety of my children is most important.

5. I agree not to discuss adult matters in my child’s presence such as court proceedings, living arrangements, or unsupervised visits.
6. I agree to bring photo identification with me to each visit. Any driver other than myself and anyone else permitted to the visitation session must provide the facilitating staff member with a copy of photo ID.
7. I understand that only persons authorized by Toby Center staff will be allowed to participate in visiting sessions; and that I am responsible for gaining approval from my visitation monitor before I may bring any additional visitors to the center.
8. I understand that the visit will be canceled if I am suspected of using abusing substances, arriving on site in a drug adduced or intoxicated condition.
9. I agree to use positive parenting while visiting with my child(ren). No corporal punishment, harsh or degrading discipline and no profanity is permitted. Visitation will be terminated immediately if there is an evidence of abuse or disrespect of the child.
10. I agree to refrain from confronting any Toby Center staff member. I will refrain from profanity, threats, and interruptions of visitations. Any disregard of Toby Center rules and evidence of inappropriate behaviors will be documented in the client file and reported to the Court.
11. I understand that all conversation must be audible to the visit facilitator. No whispering or attempts to hide conversation. Also, if a child needs assistance with toileting from a parent, the bathroom door must be open to conform to supervision standards.
12. I understand that I am responsible for my child’s behavior during the visit. If my child’s behavior is beyond my control, the program has the authority to terminate the visit.
13. I will not bring any weapons, animals, or pets to the visitation center.
14. I agree to not administer medication to my child without prior coordination with Visitation center staff, my Case Manager, and or the child’s other parent, guardian, or Caretaker.
15. I understand that the program has sole discretion to remove me from the visitation schedule or terminate a visit for any reason failure to adhere strictly to the visit schedule or rules, inappropriate or threatening behavior, signs of trauma to the child. In such circumstances, the program will retain care and custody of my child until the child is returned to the other parent/guardian and my visits at The Toby Center may be suspended until reviewed by the court.
16. I understand that I cannot leave or enter the visitation area by myself or with my children unless I have the permission of a staff member, and that the visit ends once I leave the visitation without notification and permission.
17. I understand that family members will always park where staff direct me. If driven to the visitation site, I will confirm with the Visitation Monitor ahead of the planned visitation where I may be dropped off. Other drivers may not remain on or near the visitation site (including within eye shot). This will be noted in the client file and the Court will be notified of this infraction.
18. I understand that my visits may be monitored remotely from a video camera. Interactions viewed on this video camera can be used in decisions to end visits.
19. At times, a second monitor may accompany the visitation. This is either for advanced training, or periodic observation to assure compliance by all parties.

The program is committed to maintaining a timely and accurate flow of communication with the court so that all who share responsibility for family matters will stay updated on the family’s progress with visitation.
All visitors must acknowledge the following policies:

20. I agree that my visitation file is confidential but that the Court, if involved, my attorney, DCF, area CBC and the Guardian ad Litem, if one has been appointed, shall have full access to the file.
21. I understand that my file may be transmitted electronically through e-mail to the Court, if involved, my attorney, DCF, and the Guardian ad Litem, if one has been appointed.
22. Confidentiality is important to the program. We believe you have a right to your privacy, as do your children, and the other families that visit in our center.
23. I understand that no cameras or camera functions on cell phones may be permitted during visitation sessions unless authorized by the Toby Center staff, by Dependency case manager, GAL or agreed to by both parties.
24. Video and audio taping is not allowed. Neither parents may use a cell phone or other recording device. Children are not permitted to bring in a cell phone or electronic media unless approved by staff in advance with purpose of use by both parent and child(ren).

By clicking the box, I understand that the visitation is to build a relationship between the child(ren) and visiting parent.

25. I understand that my cell phone must be turned off and that my cell phone cannot be “pulled out” at any time for any reason during visitation.
26. I understand that I may not bring or use any sort of electronic communication device during my visits. This includes, but is not limited to, iPods, iPads, Tablets, or DSi systems.

The Visitation Center location may be shared by other families. We are committed to providing a healthy, respectful, and clean environment not only for you, but for other families as well.

All visitors must agree to the following standards:
27. I understand that there is to be no use of tobacco product, e-vapes or non-medicinal medicines on the premises.
28. I agree to put all items back where they belong and clean up before leaving.
29. I understand that unless specified otherwise by my Case Manager, Toby Center Representative or Court order, I am to bring necessities that my child may need such as food, drink, and diaper bag.
30. I agree to tell my children to listen to the monitor and to try to enjoy the visitation. I will only support my child’s best interests by encouraging their time with the other parent. I will not interfere with Toby Center directives.

I understand that Court Orders take precedence over the wishes of all parties.

These rules and protocols have been presented and reviewed personally in an intake with a Toby Center Staff Member either remotely by phone or in person. By signing this document, I acknowledge that I am aware this is an agreement for visitation services with the Toby Center, that I have and understand my rights and responsibilities. I will comply with this agreement unless otherwise modified by Toby Center management and agreed to by me.

I understand additional Toby Center Staff may attend visitation sessions at any assistance and or training.

This agreement will be filed in my client file. I am also entitled to a copy of this agreement and may request it at any time without charge.

I understand that the Toby Center and staff are impartial to the visitation case. The Toby Center staff is neutral, and are concerned that both parents should be involved in the raising of their children in common to best of their ability.

I understand that the Toby Center makes no judgments, diagnosis, or recommendations for therapy or other program unless conducted by a licensed therapist as in therapeutic visitation.

I understand that the safety of all parties to Visitation is important. I will do my best to comply with these rules and understand that the Toby Center may use law enforcement, the Court and other security measures including termination of the visits if staff feel threatened and otherwise determine it is unsafe for visitation to take place.

I will not talk against the other parent to my child. I will encourage a safe and enjoyable Visitation and not block any activities my child will enjoy or otherwise control the child.

The Toby Center goal is to help all family members, all parties, all extended family members to become more comfortably involved in the lives of the children who are party to this visitation case.

“Research shows that child outcomes are maximized when both parents remain involved in their children’s lives.”

CLIENT NAME

DATE

Section Three

Step Three: Summary of Service Fees and Responsibility for Payment

Client Name

Visitation Intake & Orientation
We realize that, as a parent involved in the Family or Dependency Court system, you have many concerns. Toby Center Program professionals have the same goal as yourself, to improve your connection with your children and to also, find more meaningful means of co-parenting. Through our visitation services, we attempt to provide you with a meaningful experience that assures both parents and children emotional and physical safety, comfort and enjoyment through shared experiences. We want to help you build confidence and increased parental self-esteem. Toby Center staff considers this a partnership, and we do so with expectations and guidelines which are appropriate, and based on the standards of the Florida Clearinghouse on Supervised Visitation and the Supervised Visitation Network.

Array of Visitation Services
We offer Standard Visitation, Telephone visitation, Web-Based Visitation, and Therapeutic Visitation Services. We also document your visits and provide reports to you or your counsel and affiliated parties to your case including the Judge. These documents are available to an appointed Guardian Ad Litem (GAL), your Dependency Case Manager, or others authorized in the Court Order. You may request Toby Center staff to appear as witnesses in any hearing you schedule. There are fees and protocols for obtaining this service.

Settings
Visitation occurs in the visitation rooms designated by The Toby Center staff at the facilities associated with The Toby Center or at a family friendly location in the community.
We attempt to provide a family-friendly, safe and comfortable environment for all parties. The Toby Center staff follows court orders and will accommodate the needs of the parties as outlined in those orders.
The Toby Center reserves the right to make the final decision of location and time. We will do our best to accommodate our client families.

Additional Toby Center Services
-Therapeutic Visitation
-Supervised Visitation
-Parent Coordination
-Family Mediation
-Counseling
-Support groups
-Personal Finance

Frequency of services:
Your visits will be scheduled to best accommodate the time and location needs of all parties. Typical supervised visitation order is for one 2-hour visitation per week. The number of hours per visit and the number of visits per week can change based on your Court Order, agreement, GAL or other authority.

Preferred Day

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Preferred Time

Morning Hours Lunchtime Hours Afternoon Hours Evening Hours

Populations Served
All our families have children from different home life experiences as in divorce or other court-mandated situations. Many have children in temporary custody with other family members, a parent, or who have been sheltered and/or adjudicated dependent and placed in foster care or other family homes. New families come into our services from many sources, as from Court, agency referral, or mediation or other agreement between the parents.

Service Coordination
All questions, concerns, and communication about scheduling of regular visits and/or scheduling make-up visits should be done through your Counsel, applicable Case Manager or may be done by calling the Toby Center office to speak with Program Director. If you need to cancel a visit this must be done at least 24 hours ahead of the scheduled visit. Outside of sickness or an accident the party at fault will be billed a minimum of 1 hour at billable rate. Late fee payment will be required prior to any further visitations.

I agree to the above statement concerning the Service Coordination.

Client Name

Date

Qualifications of Staff
The Toby Center staff have completed training and orientation, based on the research and guidelines of the Florida State University Clearinghouse for Supervised Visitation and the Supervised Visitation Network. Each monitor has passed a formal security background check and often bring a personal background with divorce and parenting experience.
All Visitation Monitors have at least a high school diploma and experience working with children and families.
The Therapeutic Visitation Counselor has at least a Master’s Degree in Mental Health Counseling, Marriage and Family Therapy, Psychology, or other mental health license, and experience working with children and families.

How we can Help Your Family
Our services are here to help you keep a meaningful relationship with your children throughout your court ordered supervised visitation directed from Family Court or the Dependency Court process. The Visitation Staff is well qualified and trained to help parents and children on their path toward healthier interactions and relationships. We believe in our ability to help you and hope that you will find success within our services.
The Visitation Staff has a commitment to providing services in a manner that is welcoming and appropriate to the special needs of children and family members. We recognize that many of our families may have been traumatized or deal with high-stress situations. Our goal is to help ensure family members feel safe while they are in our facilities.
We strive to establish a relationship of trust and cooperation between family members and staff. We accomplish this by encouraging involvement and choice. All services are delivered in a ‘home like’ atmosphere or family activity in order to facilitate the healing process of the family’s relationships while keeping the children safe.

Confidentiality Policies
Client records are confidential and protected by Toby Center’s confidentiality policies. Records are retained in a supervised and locked area in each affiliate regional office of the Toby Center Visitation Program. Each party’s personal information will not be available for sharing with the other party or their counsel.
Your records are available to the Court, your Attorney, your Dependency Manager, and the Guardian ad Litem, if one has been appointed.

Possible Conflicts of Interest:
Because of the broad range of work experience and professional roles held by the Visitation Staff, there may occasionally be a conflict of interest. “Conflict” is a technical term that simply means a staff member knows a visiting family member from some place outside of work. They could be friends, go to the same church or be related in some way. In those circumstances, we want to preserve the relationships that our families have and make sure that outside and inside relationships do not mix. If this circumstance occurs, we will notify the family member, counsel, GAL and any important parties including any affiliated Dependency Case Manager of the possible “conflict” and create a plan to resolve it.

Emergency Procedures:
In the event of an emergency such as a fire or medical emergency please speak directly with visitation staff. We have first aid kits. In case of an emergency, exit information is posted on the walls throughout the building.

Check Here If You Agree to the Emergency Procedures. Please be sure to notify staff of medical concerns or protocols required for your child’s condition. If custodial parent, you are requested to please complete the Child Intake form.

Information about Performance and Outcomes:
The Visitation Monitors complete a Field Report and Field Narrative during your visit. This information is saved in your client file records and may also be submitted electronically to your Counsel, Dependency Case Manager or other authorized representative for filing with the respective Court. Your personal information is safe guarded from each party in the visitation. Field notes and Field Reports are confidential to the extent that only the parties to the visitation including legal counsel, agency management, GAL and other Court representatives involved in the matter may have access.

Field Reports are immediately available to both parties or their counsel if represented. If agency referred, your Field Report will be shared directly with the agency. Field Narratives are field notes taken by the staff monitor. These narratives are handwritten and generally not available to either party without Subpoena. There is a required fee for processing the narratives. This fee includes a processing charge of $25 plus $1.50 per page and must be prepaid. You are able to request copies of your records solely through subpoena and prepaid as explained above. For further information, contact the Regional Program Director, Dr. Mark Roseman (The Toby Center of South Florida, 561-244-0010.

As an affiliate of FSU’s Clearinghouse, The Toby Center Supervised Visitation Program participates in a statewide resource database that stores the participant’s name, date of birth, and the last four digits of his/her social security number. Our access to this database allows us to generate valuable reports that are used to enhance the quality visitation services and court policy statewide.

Ending Services
Families typically end services with the Visitation Program for one of the following reasons:

-The Visitation Program Director in conjunction with the staff monitor determines that the family no longer meets the eligibility criteria. If the Visitation Director does not believe the children or family are able to visit comfortably or safety cannot be guaranteed, services may be discontinued at that time.
-The Dependency Case Manager and/or the Dependency Court has determined that another level of care in the community better suits the family needs, such as third-party supervision, unsupervised visits, or reunification. This determination is based on completion of the Dependency Case Plan, Parent Coaching Plan, or other factors delineated by the Court.
-The visitor and/or child drops out of the Visitation Program as shown by frequent missed visits or a lack of interest in continuing services according to the Parental Agreement and/or Parent Coaching Plan.
-A parent comes to the Visitation Program under the influence of drugs, alcohol or otherwise in a condition which puts staff and children at risk.
-Client payments are delayed.
-Visitation is considered a “Successful Visitation” and occurs when a family is no longer in need of services according to the Court Order, GAL, Dependency Court Manager or the Court. Also, the Visitation Staff have determined that the client family has followed the Supervised Visitation Agreement agreed upon at the beginning of services.
-Persistent request for Toby Center and Staff to violate standing Court Order of the Court or agency instruction.
-Continued disregard of Toby Center rules and disregard to instructions given by Toby Center staff.
-If there is an attempt to bring in visitors other than named in the Court Order or approved by the Custodial parent.

Input and Grievance Policies:
Your Visitation Monitor, Regional Coordinator, or Toby Center Executive Director is available for any comments or concerns regarding visitation policies, staffing, or safety concerns. You may file a grievance form if you have concerns you do not believe are being addressed or you feel there has been a problem with your case need. All grievances must be in writing and may be emailed, faxed, or mailed to applicable Toby Center regional office.

The visitation staff may be required to offer you input during, before, or after your visits. This information may also be shared with your Dependency Case Manager. You are welcome to request input and assistance from the visitation staff at any time to i.e., prevent violation of R.O. (restraining order), and improve safety conditions during the visitation, etc.

Costs of Services:
The Visitation Program charges fees to both parties unless otherwise predetermined. There is also a separate intake and orientation fee which must be paid separately and prior to the start of Visitation. Intake fee is $95 per parent. Visitation fee is based on sliding scale, contingent upon the income of the visitation parent. Proof of income is required, i.e., pay stub, annual tax filing, other. There is an additional contract stating intake, visitation fee and payment method.

VISITATION SCHEDULE
The Visitation Schedule will be based on the latest Court Order, MSA, or other agreement between the parties and or their representatives. In the absence of a Court Order, then the Toby Center will recommend and have final approval for the meeting times and locations for the visitation sessions. Any obstruction to the visitation schedule by either party will be immediately shared with their representatives, attorneys, GALS, Court Judge or Hearing Officer, or case manager if involved.

**Research has proven that a child will thrive when both parents are involved in their children’s lives. Therefore, any effort by one or other of the parent/custodial parties to interfere with visitation is damaging to the child. It will also be immediately reported to all parties in the case, including Court and representatives.

I understand these rules above. They have been explained to me in face to face meeting or on the telephone. I have asked questions where I needed more understanding and they have been answered to my satisfaction.

Check here if you agree to these terms and acknowledge below by signing your name.

Type Client Name:

Date

Summary of Service Fees and Responsibility for Payment

This is a contract between the Toby Center and the parents/non-custodial/other party.
I am solely/jointly responsible for payment of the visitation service and intake/orientation fees.

CLIENT NAME

DATE

I understand that intake/orientation fees are to be paid in advance of scheduled visitation intake.

I understand that visitation fees are to be paid at least 24 hours in advance of the scheduled visitation service.

I understand that all fees are to be payable as court ordered or with other written agreement. Any written agreement must be provided the Toby Center for recording in the client files.

Field Notes are available by subpoena. They must be paid for in advance, $25 plus $1 per page. Contact the Toby Center.

I understand and agree with the Toby Center Fee and Payment Policy as indicated below.

Fees to be paid are as follows

1. Intake Fees ($95 per parent) The party responsible for the intake fees are:

Each parent Custodial Parent Non-Custodial

2. Visitation Fee (See Fee schedule) The party responsible for visitation fees are:

50/50 Other Percentage Allocation (if other, type amounts next)

List Percentage Allocation per Parent

Hourly Rate:
Hourly session rate is based on the visitation party providing proof of income. Proof may be check stub; tax filing; wage and salary agreement; disability paystub; court-approved indigent status.

Based on current documentation provided, the visitation fee schedule is:

Payment Guidelines:
Credit Card Payments – Preferred. Check payments – and Cash payments - discouraged.

All Payments must be made by calling The Toby Center (855-862-9236 ex 1) no later than 24 hours or more in advance of scheduled event. Non-payment will result in cancellation.

All events scheduled over the weekend (Saturday & Sunday) must be paid by the Friday prior to the event by noon. Non-payment will result in cancellation.

At the conclusion of services with The Toby Center all unpaid fees will be charged to a credit card on file.

Chargebacks:
Checks which do not clear are charged $35 standard bank fee. Any bank fee incurred by Toby Center must be paid prior to further visitations.
Late Fees:
No show and late cancellation fees will be charged to the parent at fault a minimum of 1 hour at billable rate. Late fee payment will be required prior to any further visitations.

Client Signature

Date

Phone

Email

Witness

Witness Date