DV-150 This form is attached to Supervised Visitation and Exchange Order DV-110, Temporary Restraining Order DV-140, Child Custody and Visitation Order Case Number: DV-130, Restraining Order After Hearing Mom Mom Dad Dad Other* Other* 1 2 Name of Protected Person: Other Parent's Name: *If Other, specify relationship to child: The Court Orders: 3 Mediation, Visitation and Exchange a. b. c. Parties must go to mediation at: Visitation of children is supervised. Parent to be supervised is: Mom Exchanges of children are supervised. Dad Other (name): 4 Schedule of Supervised Visits a. b. c. All visits as provided in the schedule on Form DV-140, item 4 (d) are to be supervised. Supervised visits shall be visit(s) per week of hours(s) each, to be arranged with the provider. Other schedule of supervised visits is attached. (Check here and attach a sheet of paper with "DV-150, Other Schedule" for a title.) 5 Type of Provider a. b. Professional (individual or supervised visitation center) Nonprofessional 6 Provider's Information Name: Telephone number: Address: 7 Costs Will Be Paid As Follows: Mom to pay: Dad to pay: Other: % % 8 Contact With Provider Mom to contact provider before (date): Dad to contact provider before (date): Other: 9 The court also orders (specify): This is a Court Order. Judicial Council of California, www.courts.ca.gov Rev. January 1, 2016, Mandatory Form Family Code, § 3100, 3031 Supervised Visitation and Exchange Order (Domestic Violence Prevention) DV-150, Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com