Today's Date *

MM

DD

YYYY

DHS Information *

Child Welfare Specialist Name (Please enter the ASSIGNED case worker information. If you are the assigned case worker, YOUR information will go here.)

First Name

Last Name

Phone *

(###)

###

####

CWS Supervisor's Name *

Please enter your supervisor's information.

First Name

Last Name

CWS Supervisor's Phone Number *

(###)

###

####

Why are supervised visits needed? *

Please check all that apply.

Substance Abuse

Mental Health

Domestic Violence

Abuse/Neglect

Other

Visitation Dates *

Visits can be scheduled up to 3 months in advance. Please enter the START DATE of visits.

MM

DD

YYYY

End Date *

Please enter the LAST DATE of visits for this submission.

MM

DD

YYYY

Day(s) of the Week *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday (Please call to confirm.)

Arrival Time *

Hour

Minute

Second

AM PM

Departure Time *

Hour

Minute

Second

AM PM

Who will be attending visits? *

Please check all that will be attending visits.

Mother

Father

Children

Foster Parent

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Is this a special event?

Please let us know what type of special event and if you would like to reserve the Party Room.

NO

Birthday

Holiday Party

We would like to reserve Party Room

Other