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Annual Declaration Of Professional-Therapeutic Supervised Visitation Provider FL038 - California
| Annual Declaration Of Professional-Therapeutic Supervised Visitation Provider Form. This is a California form and can be used in Family Law Marin Local County . |
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SUPERIOR COURT OF CALIFORNIA County of Marin ANNUAL DECLARATION OF PROFESSIONAL SUPERVISED VISITATION PROVIDER (pursuant to Family Code Section 3200.5 and California Rules of Court, Standards of Judicial Administration, Standard 5.20) I declare that: I am 21 years of age or older; I have not been convicted of driving under the influence (DUI) within the last 5 years; I have not been on probation or parole for the last 10 years; I have no record of a conviction for child molestation, child abuse, or other crimes against a person; I have proof of automobile insurance and use appropriate vehicle restraints if transporting the child; I have no civil, criminal, or juvenile restraining orders within the last 10 years; I have no current or past court order in which the provider is the person being supervised; If I am unable to speak the language of the party being supervised and of the child, I will provide a neutral interpreter over the age of 18 who is able to do so; and I agree to adhere to and enforce the court order regarding supervised visitation. I meet the qualifications of a provider and have received 24 hours of training in the following subject areas: (a) The role of a professional provider. (b) Child abuse reporting laws. (c) Recordkeeping procedures. (d) Screening, monitoring, and termination of visitation. (e) Developmental needs of children. (f) Legal responsibilities and obligations of a provider. (g) Cultural sensitivity. (h) Conflicts of interest. (i) (j) Confidentiality. Issues relating to substance abuse, child abuse, sexual abuse, and domestic violence. (k) Basic knowledge of family and juvenile law. Please indicate your agreement by checking each box in front of each numbered paragraph. 1. I understand that my principal responsibility is to observe these visits in person and to take action immediately if a child needs protection, reassurance, or a break of any kind from the visit. I agree to perform my duties as a supervised visitation provider neutrally and without any bias or favoritism toward or against the supervised parent. 2. I agree that I will not, under any circumstances, leave the child with the supervised parent outside my presence. FL038 (Rev. 1/13) ANNUAL DECLARATION OF PROFESSIONAL SUPERVISED VISITATION PROVIDER (Mandatory Form) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 3. I have received a copy of A Guide for the Supervised Visitation Provider (form FL039). I understand the Guide, and agree to comply with each provision in it. 4. I agree that I will report to the court if either parent violates any of the rules described in A Guide for the Supervised Visitation Provider (form FL039) and, if ordered by the court, on all the observations I make during the visits. If any of the above boxes are not checked, please explain: DATE SIGNATURE OF SUPERVISED VISITATION PROVIDER PRINT NAME OF SUPERVISED VISITATION PROVIDER STREET ADDRESS CITY / ZIP CODE TELEPHONE NUMBER EMAIL ADDRESS FL038 (Rev. 1/13) ANNUAL DECLARATION OF PROFESSIONAL SUPERVISED VISITATION PROVIDER (Mandatory Form) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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