Supervised Parenting Time/Visitation (Non-Parent) Order - Agency Only (Rev. 03/04/16) CCDR N036 A IN THE CIRCUIT COURT OF THE COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS IN RE: q Marriage q Civil Union q Legal Separation q Allocation of Parental Responsibilities q Visitation (Non-Parent) q Support q Parentage of: No.: ___________________________________ Calendar: ______________________________ ______________________________________________________ Petitioner and ______________________________________________________ Respondent SUPERVISED PARENTING TIME / VISITATION (NON-PARENT) ORDER - AGENCY ONLY This case coming to be heard on q Petitioner's q Respondent's q Other for _________________________________ , all parties being advised of the premises, q Petitioner (q with counsel q pro se) q Respondent (q with counsel q pro se) appearing and this court having jurisdiction over the subject matter, q by agreement q after hearing, IT IS HEREBY ORDERED that the q Petitioner q Respondent's q Other shall have 7620 q Supervised parenting time q Safe exchange with ___________________________________________________________ at 7625 q Supervised visitation (non-parents) Name(s) of Child(ren) q A. Notice of Personal Identity Information within Court Filing form (CCG 0502) has been filed under seal, containing the full name(s) and date(s) of birth of the minor(s). 7621 q Order for Supervised Parenting Time - Agency Only 7626 q Order for Supervised Visitation (non-parent) - Agency Only (Agency checked below is the preferred provider.) q Apna Ghar 4350 N. Broadway, 2nd Floor; Chicago, IL 60602; Telephone: (773) 334-0173; Fax: (773) 334-0963 q Metropolitan Family Services 3843 W. 63rd Street,; Chicago, IL 60629; Telephone: (773) 884-3310; Fax: (773) 884-0003 q Mujeres Latinas en Acción 1823 W. 17th Street; Chicago, IL 60602; Telephone: (773) 890-7676; Fax: (773) 890-7650 q Other professional supervisory service _______________________________________________________________________ _____________________________________________________________________________________________________ B. SPECIAL CONSIDERATIONS q Order of Protection Protected Party: ________________________________________ Order No. ______________________ q Other: ________________________________________________________________________________________________ C. Identification of parties, children, attorney, GAL, and/or child representative Child(ren)'s Full Name(s) Age D.O.B. Person with whom Child(ren) Reside(s) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Petitioner Name: ___________________________________________ *Address: _________________________________________ _________________________________________________ Date of Birth: ______________________________________ Home Telephone No.: _______________________________ Work Telephone No.: ________________________________ Petitioner's Attorney Name: ___________________________________________ Address: __________________________________________ _________________________________________________ Telephone No.:_____________________________________ Fax: _____________________________________________ (* 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 Page 1 of 2 Supervised Parenting Time/Visitation (Non-Parent) Order - Agency Only Respondent Name: _____________________________________________ *Address: ___________________________________________ ___________________________________________________ Date of Birth: ________________________________________ Home Telephone No.: _________________________________ Work Telephone No.: __________________________________ Other Name: _____________________________________________ *Address: ___________________________________________ ___________________________________________________ Date of Birth: ________________________________________ Home Telephone No.: _________________________________ Work Telephone No.: __________________________________ Child's Representative/Guardian Ad Litem Attorney for Child Name: _____________________________________________ Address: ____________________________________________ ___________________________________________________ Telephone No.:_______________________________________ Fax: _______________________________________________ Respondent's Attorney (Rev. 03/04/16) CCDR N036 B Name: ___________________________________________ Address: __________________________________________ _________________________________________________ Telephone No.:_____________________________________ Fax: _____________________________________________ Other Attorney Name: ___________________________________________ Address: __________________________________________ _________________________________________________ Telephone No.:_____________________________________ Fax: _____________________________________________ D. Suggested schedule of parenting time or visitation: Please indicate frequency, i.e. weekly or monthly ___________________________________________________________________________________ (suggested parenting time or visitation schedule is contingent upon supervised visitation center availability and parties must make every effort to make themselves available for supervised visitation.) E. Parenting time or visitation scheduling restrictions (optional): __________________________________________________________________________________________________ Costs will be paid as follows: q No Charge: 4386 q Payment is ordered as follows (%): ________________________________________________________________ G. Contact with provider: q Petitioner to contact provider before (date): __________________________________ , __________. q Respondent to contact provider before (date): ________________________________ , __________. 4406 H. This matter is set for status on ______________________________ at ___________ q a.m. q p