APPLY NOW

Fill out the form below and we will get back to you as soon as possible to facilitate our sessions with you and begin to build long lasting relationships with your children.

Application form

Please fill out as accurately as possible.

Your Details

Your Role *Child currently lives with meChild will be supervised with me

First Name *

Surname *

Email Address *

Phone Number

Street Address *

City *

State/Province *

ZIP / Postal Code *

Your Solicitor's Details

Solicitor's Name

Street Address

City

State/Province

ZIP / Postal Code

Phone Number

Email Address

Children's Details

Child 1 Name *

DOB

Child 2 Name

DOB

Child 3 Name

DOB

Child 4 Name

DOB

Independent Children's Lawyer's Details

Solicitor's Name

Street Address

City

State/Province

ZIP / Postal Code

Phone Number

Email Address

Current Living Situation

Is there an Intervention Order in place? *YesNo

Is regular drug and alcohol screening required *YesNo

Is there a current court order or parenting plan in place? *YesNo

Which parent will be financially responsible for paying the agency fees? *I amOther Parent

Do you have a return date for court, mediation, FRC, etc?

What is the duration and frequency requirement of your supervised time? (eg 2 hours weekly)

Agreement

By submitting this form, you agree that the information provided is correct to the best of your knowledge. You also acknowledge that at least 24 hours notice is required for cancellation or full fee may be charged. A copy of relevant court orders is to be provided to the agency as soon as possible. You further acknowledge you have read and understood our processes and procedures.

Consent *

By submitting this form, I agree that the information provided is correct to the best of my knowledge. I also acknowledge that at least 24 hours notice is required for cancellation or full fee may be charged. A copy of relevant court orders is to be provided to the agency as soon as possible. I further acknowledge I have read and understood your processes and procedures.

Terms and Conditions
Privacy Policy