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...
- ____ Domestic Violence
- ____ Child abuse by visiting party
- ____ Abuse of child by family member, if so, relationship:________________
- ____ Mental health issues
- ____ Living conditions
- ____ Flight risk, if so, has there been prior abduction?______
- ____ Neglect of child(ren)
- ____ Sexual abuse of child(ren)
- ____ Sexual abuse of another child by visiting party
- ____ Reunification, if so, how long since visiting party saw child?__________
- ____ Physical abuse of child(ren)
- ____ Drug use, including illegal use of prescription drugs
- ____ Alcohol abuse
- ____ Child Protective Services (CPS) involved
- ____ Incarceration of visiting party: if so, how long_____ Reason____________________
- ____ Inconsistent visits
- ____ 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.