425, 10404 - 149 Ave

Edmonton, AB, T5E 2M5

P| 780 413 6140 F| 780 413 6455

Helping People Help Themselves

105, 13245 140 Ave Edmonton, Ab | T6v 0e4 info@familyconnectionsinc.net P | 780 413 6140 F | 780 413 6455
Supervised visits | 587 372 3557 SAS@familyconnectionsinc.net

Your Intake may take 1- 3 weeks to process.

When submitting this intake, we ask that any personal opinions be omitted. It is Family Connections Inc. Policy to follow all guidelines stated in the court orders and to remain a neutral party. If you have any questions, please email sas@familyconnectionsinc.net

Today's Date

YYYY

Are you the custodial parent

Name of Person Submitting Intake

First Name

Last Name

Phone of Applicant

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Relationship to child/ren

Family Name

Last name of child/ren

Custodial Parent / Adult

Child/ren Placement Address

If known, if not please put N/A

Children's Name/s and DOB

Please List Each child and their DOB

PARENT INFORMATION

*For contact purposes only. No visits can take place until we can establish communication. We require a current email and/or phone number. If you do not have this, please contact your lawyer before submitting this intake form.

Mother's Name

First Name

Last Name

Phone

(###)

###

####

Father's Name

First Name

Last Name

Phone

(###)

###

####

EMERGENCY CONTACT

Contact information for a family representative or emergency contact.

First and Last name

Emergency Contact

First Name

Last Name

Phone number

(###)

###

####

VISIT INFORMATION

Visit Information

Please list any details for the visit and or court orders. If things like taking photos, gifts, and phone calls are not outlined in the court order. It will be up to the discretion of the program Manager and the supervisor.

Special needs

e.g., Specialized diet, medication, health concerns, allergies, etc.

Visit Date and Times

We will contact you if the requested dates and times cannot be fulfilled. **We do not recommend requesting specific times on a court order. As our booking times are dependant on many different visit lengths.**

Visit Location

We require a minimum of three successful facility visits before we will discuss a community visit.

Approved Court Ordered Visitors

Please list the names of all people who CAN attend a visit. If there is no court order and this is not outlined, it will be up to the custodial parent who can attend the visit.

VISIT GOALS AND PHASE

List two goals relevant to visiting

ie: I would like my child to build a healthy relationship with their mom/dad. or I would like to learn some positive parenting skills.

Visiting Phase and Purpose of Visit

Please choose one phase.

Initial Phase: To establish a relationship between visiting parent and child/ren.

Middle Phase: To Involve family members and others working to meet visit goals.

Transition Phase: To maximize the opportunities for the child-parent contact and transition into unsupervised visitations.

LEGAL INFORMATION

Are you able to provide a Court Order for our records?

Known Risks or Any Important Information

List any court-ordered specifics. If there is no court order please write N/A.

Are there any restraining orders involved?

We ask that a copy of the restraining order be emailed to sas@familyconnectionsinc.ca

GUIDELINES

Please read carefully and Initial each Guideline

Our fee is $50.00 per hour with a minimum 2-hour call out, and any visits outside our main office will result in a travel fee of $35 per hour. We are a fee-for-service program. If a report for court or lawyer is requested, there is a fee of $50.00 an hour billed at a minimum of two hours. Any court-appointed appearances are billed at $1000.00.