2HOME KIDS PROGRAM
Red *
indicates a response is required.
Which Hannah's House service are you signing up for?
*
Supervised Visitation
Safe Exchanges
Name
*
First Name
Last Name
Are you the Custodial or Non-custodial Parent?
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Custodial
Non-custodial
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
Alternative Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Other Party's Name
First Name
Last Name
Other Party's Phone Number
-
Area Code
Phone Number
Other Party's Email
example@example.com
Who Referred You?
*
Per the Court Order, who has LEGAL custody?
*
Have you used Hannah's House services before? When?
*
Children
*
Please provide the ALL children's full name (as they appear in court order documentation), their dates of birth and the sex of each child.
How long has it been since the children had contact with the Non-Custodial parent? are there phone or skype calls?
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Why is supervised visitation recommended in this situation?
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For example: due to a Restraining Order, due to child abuse, mental illness, etc.
How many hours per week are ordered?
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For example: due to a Restraining Order, due to child abuse, mental illness, etc.
Has there been a previous order for supervised visitation?
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If so, where did you receive services and the dates of services.
Next Court Date?
-
Month
-
Day
Year
Date
Next Mediation Date?
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Month
-
Day
Year
Date
Is there any risk of flight/abduction on the part of either parent?
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Yes
No
Are there any Restraining Orders in effect?
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Yes
No
Is there a history or current concern about Domestic Violence?
*
Yes
No
Is there a history or current concern about Child Abuse (physical or sexual)?
*
Yes
No
Is there a history or current concern about Alcohol or Drug Abuse?
*
Yes
No
If YES to above question, please indicate what type of alcohol or drug abuse.
Is there an order for alcohol or drug assessment/testing?
*
Yes
No
Please indicate if there are any legal issues pending that are related to the case.
*
Indicate "NA" if no legal issues pending.
Have you heard about out Transitions Family Program (psycho-educational & clinical services)?
*
Yes
No
I understand I will receive acknowledgement of receipt of this screening form within 48 hours and I will then be scheduled for a required new-client orientation. I also understand Hannah's House will start working on contacting the other party to also get them started on the intake process, if they have not already done so.
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I Agree
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Please verify that you are human
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