Personal and Family Information
Emergency Contact Information
In the event of an accident who do you give permission to assist with emergency regarding the minor child(ren):
Emergency contact person(s) are expected to be familiar with the agency’s guidelines and procedures. Calvary Counseling Center reserves the right to refuse to work with anyone who is disruptive. I authorize my emergency contact to be called if the agency staff consider it necessary and the safety of the minor is compromised. I release and hold Calvary Counseling Center harmless from all claims and I assume all risk for claims which may arise as a result of acts or omissions by my emergency contact person.
I authorize my emergency contact person to be called if agency staff consider it necessary. In return for my use of the services of Calvary Counseling Center, Inc , I release Calvary Counseling Center and its employees’ intern, and volunteers from all claims and I assume all risk for claims which may arise as a result of acts or omission by my emergency contact person(s).
Signature of Custodial Parent/Legal Guardian
Court Information (If Applicable)
Child(ren) Information
Please list all child(ren) who will engage in Supervised Visitation:
30. Contact information
Custody and Visitation Arrangements
Welcoming Letter to Parent
Greetings,
Welcome to Calvary Counseling Center. We are pleased to have you and your family join our agency. Our goal is to provide a secure environment where children can feel safe with their parents. We aim to offer a neutral setting that respects all individuals involved. The supervised visitation guidelines we have in place are designed to prioritize the well-being and safety of child(ren) and adults alike. At Calvary, our utmost priority is ensuring the safety and welfare of the families we serve.
Our guidelines outline the visitation appointment procedures and define the responsibilities of parents/guardians during their time at Calvary Counseling Center. We aim to offer support and guidance to parents as they work towards maintaining and strengthening relationships with their children in a safe, family-oriented environment.
Thank you for choosing our supervised visitation program. We wish you and your family all the best.
Best,
Calvary Counseling Center
Supervised Visitation Policy Procedures and Protocols
Calvary Counseling Center’s Policy Procedures and Protocols
It shall be the policy of Calvary Counseling Center that
Supervised Orientation:
Each parent/guardian are required to be interviewed and assessed separately. Orientation is for adults only Child(ren) are not allowed at the initial supervised visitation orientation. Post orientation minor child(ren) will visit the agency and meet staff prior to supervised visitation commence.
Ability to Intervene:
Supervised visitation staff shall have the ability to intervene in supervised visitation. Every Calvary staff shall be objective in their observation and intervene effectively to maintain the safety of the parties and the child(ren).
Neutrality of Calvary Staff :
All Calvary staff must maintain a neutral role by refusing to discuss the merits of the case or agree with one party over another it will be the policy of Calvary counseling center that any discussion between the parties shall be for the purpose of arranging visitations and providing and maintaining the safety of the children and the parents.
Conflict of Interest:
In order to avoid conflict of interest Calvary shall be not financially dependent on the person being supervised; And employee of the person being supervised or in intimate relationship with the person being supervised or related to the person being supervised
Staff Qualification:
• Be 21 years of age or older:
• Submit to a background check
• Calvary Counseling Center staff shall not have been convicted of operating under the influence(OUI/DWI)
• Have no civil or criminal restraining order issued against the supervisor/staff within the last 10 years.
• Be able to speak the language of the party being supervised and of the child or provide a neutral interpreter
• Shall be knowledgeable of laws relevant to domestic violence and best practices for supervised visitation
• Know the child abuse and confidentiality reporting laws
Documentation of Visitation:
Calvary Counseling Center staff should keep minimal documentation of the visitation. Copies of the supervised visitation log form shall be kept in file for no less than five years period. Calvary Counseling Center staff will utilize minimal documentation that will be limited to facts of arrival of the minor(s) what items where brought to the Supervised visitation session and who brought specific items and merchandise to the session. Staff will document any act that violates agency’s policy, all contact between Calvary staff, in person, and writing, or by phone with either party the child, the court, attorneys shall be documented in the case file. All entries should be dated and signed by the person recording the entry or by the Clinical director of the agency.
Safety and security Procedures:
It will be the objective of Calvary counseling center to make every reasonable effort to ensure the safety and the welfare of the child(ren) and the adults during the visitation period Calvary counseling center has established a working relationship with local law enforcement agencies and the court systems. Our partnership with law enforcement agency includes the establishment of emergency procedures to best ensure that the safety needs of the staff and their clients and the staff will be met.
Calvary Counseling Center Shall:
• Prepare a written agreement to be signed by the parties between commitment of supervised visitation. The agreement shall inform each party of the terms and the conditions of supervised visitation. Conduct an intake and screening procedure for intake shall include separate interviews with each party.
• Have each child visit Calvary Counseling Center post initial intake or orientation of both parent/guardian
• Obtain documentation of legal court documents, proceedings and relevant documents regarding current custody and visitation court if applicable. Any orders including the supervised visitation order a report of any written reports of allegations of domestic violence or abuse health history will be made available to the agency. Any chronic health issues of the minor child and any chronic health conditions and a statement as to the minor child's health shall be reported to the agency at the initial assessment.
• All parties are required to disclose if previously supervised visitation services were rendered at another facility and its outcome. All parties agree to explain if previous SV services were terminated due to disruptive behaviors and or threats to all parties included and the supervised visitation process.
• Agency reserve the right to suspend or terminate a supervised visit if agency determines that the risk factors present jeopardize the safety and the welfare of any person.
• Advise all parties before commencement of supervised visitation that no confidential privileges exist;
• Agency will report suspected child abuse to appropriate agency.
Safety Consideration for Sexual Abuse Cases:
• In cases where there are allegations of sexual abuse the following additional terms and conditions shall be applied by Calvary Counseling Center:
• No exchange of gifts, money, or cards
• No photographic audio taping or videotaping of the child;
• No physical contact with the child lap sitting hair combing stroking prolonged hugging wrestling tickling horse playing or changing diapers
• Non-custodial parent will not be accompanying the child to the restroom;
• No whispering, passing notes, hand signals, or body signals will be permitted and;
Confidentiality:
It will be the policy of Calvary Counseling Center to make all parties aware that communications between parties during supervised visitation are not protected by any privilege of confidentiality. All parties will be informed that patient privilege does not apply during therapeutic supervision.
All personal information will remain confidential. There should never be an exchange or request for address, phone numbers, locations, or names from parents or children during any service or appointment.
Temporary Suspension or Termination of Supervised Visitation:
Calvary counseling Center will make every reasonable effort to provide a safe visit for the child(ren) and non-custodial parent. If at any time Calvary Counseling Center staff determines that the rules of the visitation have been violated the child has become acutely distressed or the safety of the child(ren) and a parent or Calvary staff is at risk the visit will be i.e., terminated, interrupted , and or rescheduled to a later date pending review by the agency’s Clinical Director.
Should Calvary Counseling Center suspend services pending review a written notice will be provided to the custodial and non-custodial parent making them aware of the agency’s final disposition regarding supervised visitation services
Visitations:
Visits are for the benefit of you and your child. The Calvary counseling center will assist in making your visit.
Appointment:
Visits must be confirmed by calling the Calvary Counseling Center office no later than 48 hours in advance.
• No one but the visiting parent can confirm the visit.
• If the visit is not confirmed on time the visit will be cancelled and a cancellation fee will be charged.
Arrive On Time:
It is important to your child's children and to the next family on schedule for parents to arrive on time
• The visit will not occur if the parents are more than 15 minutes late. Arriving more than 15 minutes late is recorded as a failure to participate.
• Extra time will not be given if a parent is late.
• No pets are allowed during supervised visitation.
Before The Visit:
• A visit will be terminated if anyone arrives at the facility and is believed to be under the influence of any mind altering substance be it prescribe or non-prescribed drugs. Participants shall NOT use drugs or alcohol prior to or during visitation. Suspicion of narcotics/alcohol use will not be tolerated. No refunds will occur.
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• Weapons or anything that could be used as a weapon are not allowed at visit
• No party is allowed to bring anyone with you to the supervised visitation. Supervised Visitation is for parties that are named in the court order or for non-custodial/guardian. NO VISTIORS ALLOWED.
• Participants are NOT allowed to bring gifts/toys or other items unless it has been agreed upon with all parties. (Birthdays are the exception).
• Participants are NOT allowed to bring sick children to visitations; fever of 100, diarrhea, vomiting, unexplained or contagious rash. Parents should be free of contagious conditions. All must be symptom free for 24 hours or taken medicine for 24 hours and must have Doctor’s note to reschedule a visit. NO REFUNDS. If custodial parent does not provide medical documentation, they are responsible for payment for missed visit.
• No pets are allowed at the locations. Tell your monitor if you have a pet prior to the Onsite visit as some staff are allergic to some pets.
During The Visit:
• All Parties must be within sight and sound during all supervised visitation at all times.
• Termination procedure: Monitors will offer warning of infraction which may result in immediate termination. OR 3 Warnings of minor infractions during a visit will result in immediate termination. Custodial parent or guardian will contacted to come and retrieve child(ren) Police may be called for assistance. There is a loss of payment. NO refund.
• The court case cannot be discussed in the child or children's presence. No negative talk about anyone including the child the child's siblings other parent judge caretaker social worker or Calvary staff is not allowed. Polite language is required at all times. Avoid swearing or name calling.
• Do not use the child or Calvary staff to communicate with the other parent in supervised visitation. All verbal communications must be understood by the Calvary counseling staff whispering passing nose or using hand signals is not allowed
• If child seems uncomfortable with physical contact such as tickling, hugging, kissing or holding please stop immediately. You may discuss your child's reaction with the Calvary staff.
• It is important for you to manage your child's behavior during the visit. Positive words of discipline are to be used if discipline is needed. Redirecting your child or brief time out are recommended. If you want more parenting help. Contact Calvary staff for therapeutic supervision services.
At The End of The Visit:
• All visits shall end at scheduled time
• It is the parents’ responsibility to begin cleaning up the visitation area 10 to 15 minutes before the visit is over. Clean up includes picking up any trash from the visit and using disinfected wipes to clean the toys.
• Goodbyes being immediately after clean up help make goodbyes easier for your child by making them positive.
Cancellation:
• Call the Calvary counseling center staff at least 48 hours in advance to cancel the visit. Leave a voicemail message if the Calvary staff is not available. This will provide Calvary counseling adequate notice so that your child will not be disappointed at the last minute.
• Cancellations are only allowed due to illness. Medical documentation is required to rescheduled visit. No refund is allowed. If there is no doctor's note the custodial parent will be responsible for the fee of the missed visit. No refunds.
• Excessive cancellations or missed visits will not be rescheduled.
Suspended Visits:
• Failure to participate for three pre-arranged visits in a row will result in suspension of visits
• Custodial and Non-custodial parent must contact any referring agency and make them aware that services were terminated due to non-compliance.
• If the referring agency cancels a visit or your child is sick, make-up time will be mutually arranged between all parties. Make up time may me more time given to a future visit. Visit supervised by our agency may be made available during weekdays and weekends.
I have read and understand and agree with the agency’s policies and procedures. I agree and shall abide by all stated, written and discussed policy, procedures, rules and guidelines.
Supervised Visitation Services & Fees:
I understand the results of noncompliance of agency policies and procedures visitation can be terminated and loss of payments.
Supervised Visitation & Designee Emergency Contact Form
Custodial Parent ONLY
No one other than the custodial parent slash guardian will be permitted to drop off or pick up the child for supervised visitation unless the custodial parent designate another person by completing this form.
Designee; You are giving another adult permission to drop off pick up your child. This procedure is required in the event that you are unable to bring your child to visits. Attach a copy of a valid driver's license or government issued ID photo for our records. Please provide the names and contact of a primary and secondary emergency contact person that you grant permission to pickup the child(ren) in the event of emergency. Please inform these individuals that you have asked them to serve as an emergency point of contact and they are aware they must adhere to Calvary’s policies, procedures and protocols.
Primary Contact:
Secondary Contact
Attach copy of valid/current government issued ID of the primary and secondary emergency contact individuals.
Designees an emergency contact person are expected to be familiar with Calvary Counseling Centers guidelines and protocols . Calvary Counseling Center reserves the right to refuse to work or service anyone who is disruptive and disrespectful. I authorized my designee to drop off pick up my child or children. I authorized my emergency contact to be called if the Calvary Counseling Center staff considers it necessary. In return for my use of services of Calvary Counseling Center I release Calvary Counseling Center and its employees from all claims and I assume all risk for emergencies which may arise as a result of the act of omission by my designee or emergency contact person(s).
Medical /Allergies Form
Completed By Custodial Parent Only
This form is to be completed when child(ren) has special dietary requirements during the visitation process please complete as necessary
Additional Information:
