REASONS FOR REFERRAL TO SAFE PROGRAM

Please site information presented in court that resulted in the requirement of supervised
visits. Also, please provide any other information that may be helpful for us to serve your
family.

Has there ever been...

  1. ____ Domestic Violence                                                                        
  2. ____ Child abuse by visiting party
  3. ____ Abuse of child by family member, if so, relationship:________________
  4. ____ Mental health issues
  5. ____ Living conditions
  6. ____ Flight risk, if so, has there been prior abduction?______
  7. ____ Neglect of child(ren)
  8. ____ Sexual abuse of child(ren)
  9. ____ Sexual abuse of another child by visiting party
  10. ____ Reunification, if so, how long since visiting party saw child?__________
  11. ____ Physical abuse of child(ren)
  12. ____ Drug use, including illegal use of prescription drugs
  13. ____ Alcohol abuse
  14. ____ Child Protective Services (CPS) involved
  15. ____ Incarceration of visiting party: if so, how long_____ Reason____________________
  16. ____ Inconsistent visits
  17. ____ Other, describe below

  • Are you currently on probation/parole?  Yes _____No _____
      If so, provide name and phone number of probation/parole officer. We will need a copy of            
probation/parole conditions/restrictions.

  • Name:_______________________Phone:____________________
        Details of violation: Charge:_____________________________Date:________________
        Provide details below.

       
        Please use the reverse side to provide additional information. Include any special needs of your
child(ren), including how they may react to seeing the visiting party.


        Parties are able to view the site prior to first visit if they desire. Call the office to schedule

        Counseling is available to the custodial party and child(ren) at no cost.