Application For Supervised Time

Your role *

Please select your role in this application.

Child currently lives with me

Child will be supervised with me

Name *

First Name

Last Name

Other parent's name

First Name

Last Name

Is there an intervention order in place? *

Yes

No

Is regular drug / alcohol screening required? *

Yes

No

Which parent is responsible for payment of agency fees? *

I am

Other parent

Is there a current court order or parenting plan in place? *

Forward details to the agency as appropriate

Yes

No

Electronic signature *

By submitting this form, you agree that the information provided is correct to the best of your knowledge. You also acknowledge that at least 24 hours notice is required for cancellation or full fee may be charged. A copy of relevant court orders is to be provided to the agency as soon as possible. You further acknowledge that you have read, understood, and agree to the Procedures and Services Agreement.

Tick to sign