Print Form Supervised Visitation Order-Agency Only Clear Form (9/28/11) CCDR 0036 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION _____________________________________________________ Petitioner v. No. _______________________________________ _____________________________________________________ Respondent SUPERVISED VISITATION ORDER-AGENCY ONLY This case coming to be heard on ‰ Petitioner's ‰ Respondent's ‰ Other for _________________________________, all parties being advised of the premises, and this court having jurisdiction over the subject matter, ‰ by agreement ‰ after hearing, IT IS HEREBY ORDERED that the ‰ Petitioner ‰ Respondent ‰ Other shall have A. 4620 ‰ Supervised Visitation ‰ Safe Exchange with ___________________________________________________________ (Name(s) of Child(ren)) at (agency checked below is the preferred provider) ‰ Apna Ghar, Supervised Visitation and Safe Exchange program 4753 N. Broadway, Suite 632, Chicago, IL 60602 Telephone: (773) 334-0173 Fax: (773) 334-0963 ‰ The Branch Family Institute, Supervised Visitation and Safe Exchange program 3139 W. 111th Street, Chicago, IL 60655 Telephone: (773) 238-1100 Fax: (773) 238-4095 ‰ Mujeres Latinas en Acción, Supervised Visitation and Safe Exchange program 1823 W. 17th Street, Chicago, IL 60608 Telephone: (773) 890-7676 Fax: (773) 890-7650 ‰ Other Professional Supervisory Service ____________________________________________________________________ __________________________________________________________________________________________________ B. Special Considerations ‰ Order of Protection _______________________________________ Order No. __________________ ‰ Other: _____________________________________________________________________________________________ Protected Party: C. Identification of Parties, Children, Attorneys, GALs Child(ren)'s Full Name(s) Age D.O.B. Person with whom Child(ren) Reside(s) _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Petitioner: Petitioner's Attorney: Name: ____________________________________________ Atty. No. _______________ Address*: _________________________________________ _______________________________________________ Address: _____________________________________________ ____________________________________________________ Telephone: ____________________________________________ Fax: _________________________________________________ _________________________________________________ Date of Birth: ______________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________ Name: (*If party has not disclosed an address, that party shall designate an alternative address for the purpose of notice.) (OVER) (9/28/11) CCDR 0036 B Respondent: Respondent's Attorney: Name: ____________________________________________ Address*: _________________________________________ Atty. No. _______________ Name: _______________________________________________ Address: _____________________________________________ _________________________________________________ Date of Birth: ______________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________ ____________________________________________________ Telephone: ____________________________________________ Fax: _________________________________________________ Other: Other's Attorney: Name: ____________________________________________ Address*: _________________________________________ Atty. No. _______________ Name: _______________________________________________ Address: _____________________________________________ _________________________________________________ Date of Birth: ______________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________ ____________________________________________________ Telephone: ____________________________________________ Fax: _________________________________________________ Child's Representative/Guardian ad Litem/Attorney for Child Atty. No. _______________ Name: ____________________________________________ Address: __________________________________________ _________________________________________________ Telephone: ________________________________________ Fax: _____________________________________________ _____________________________________________________________________________ _____________________________________________________________________________________________________ D. Suggested Schedule of Visits: (Suggested visitation schedule is contingent upon supervised visitation center availability and parties must make every effort to make themselves available for supervised visitation.) E. Visitation scheduling restrictions (optional): ___________________________________________________________________ __________________________________________________________________________________________________ F. Costs will be paid as follows: ‰ No charge ‰ Payment is ordered as follows (%): ___________________________________________ G. Contact with provider: ‰ Petitioner to contact provider before (date): ___________________________, __________. ‰ Respondent to contact provider before (date): ___________________________, __________. H. This matter is set for status on _____________________________, __________ at ______________ m. in Room ___________. I. The attorney for _______________________________________ shall contact the the referred agency within 10 days of the entry of this order and transmit all appropriate pleadings with this order within 10 days of the entry of this order. All parties shall promptly and fully comply with the requirements of any referring agency. Atty. No. _______________ Name: ________________________________________________ Atty. for: _____________________________________________ Address: _______________________________________________ City/State/Zip: ________________________________________ Telephone: ____________________________________________ Fax: ________________________________________________ ENTERED: Dated: _________________________________, ___________ __________________________________________________ Judge (*If party has not disclosed an address, that party shall designate an alternative address for the purpose of notice.) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Judge’s No.