Roots of Home Supervised Visits Professional Referral 
Professional Referral Form for Supervised Visits
Your First Name (not the client you are referring) *
Your Last Name (not the client you are referring) *
Your Email (not the client you are referring) *
Your Phone number (not the client you are referring) *
What is the name of the parent/caregiver you are submitting this referral for?
*
What is the client's phone number and/or email address? *
Please provide as much context as possible as to why this family is being referred for supervised visits? *
Will a copy of the court order be provided? *
Is the client willing to sign a Release of Information Form, allowing Roots of Home to share information with the court or agency requesting these visits? *
What is the frequency of visits you are requesting for this family? *
What are the first names, gender and ages of the child(ren) that will be attending visits? *
Are there any specific concerns/behaviors you have that you think our team should be aware of while working with this family that you haven’t already mentioned? *
Please identify the strengths of the parent/caregiver that you believe positively impact their child(ren)?
*
From your perspective, what would the parent need to demonstrate that would indicate supervised visits are no longer needed? *
Can the foster parents and parents have contact with one another?
*
Who will be transporting the child(ren) to and from the visits?  *
Are there any no contact orders between family members? *
If yes, please list the names of people on the no contact order.
Are there any questions that we can answer for you about the supervised visitation process?
Who referred you to Roots of Home?
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