Roots of Home Supervised Visits Self Referral 
Self Referral Form for Supervised Visits
First Name *
Last Name *
Email *
Address *
Phone number *
Please select the best method and time to contact you. *
Required
Why are you are being required to participate in supervised or semi-supervised visits? *
Will a copy of the court order be provided? *
Are you willing to sign a Release of Information Form, allowing Roots of Home to share information with the court or agency requesting these visits? *
How often are you requesting visits? *
How long of a visit are you requesting? *
Please select the days that work best for you to schedule visits. *
Required
Please select the best times for you to schedule visits. *
Required
What are your goals for these supervised visits? *
First Name, Gender and Age of the child(ren) participating in these supervised visits. *
What are some activities that your child(ren) love(s)? *
What activities do you like to do as a family? *
Are there any behaviors that your child(ren) exhibit that are challenging for you to deal with?
 *
What are things that help calm your child(ren) down when they are upset?
 *
How do your child(ren) do with making transitions and are there any special accommodations they need when transitioning between activities or at the end of a visit?
 *
What would your child(ren) say is their favorite part about their relationship with you?
 *
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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