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Supervised Visitation-Agency Only CCDR 0036 - Illinois

Supervised Visitation-Agency Only Form. This is a Illinois form and can be used in Domestic Relations Cook Local County .
 Fillable pdf Last Modified 3/6/2015

Print Form Clear Form Supervised Visitation Order - Agency Only (Rev. 12/08/14) CCDR 0036 A IN THE CIRCUIT COURT OF THE COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS __________________________________________________________ Petitioner v. __________________________________________________________ Respondent No. ________________________________ 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, Petitioner ( with counsel pro se) Respondent ( with counsel pro se) appearing and this court having jurisdiction over the subject matter, by agreement after hearing, IT IS HEREBY ORDERED that the Petitioner Respondent's Other shall have Safe exchange with _______________________________________________________________ at Name(s) of Child(ren) 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). (agency checked below is the preferred provider) Apna Ghar; Supervised Visitation and Safe Exchange program 4350 N. Broadway, 2nd Floor; Chicago, IL 60602; Telephone: (773) 334-0173; Fax: (773) 334-0963 Metropolitan Family Services, supervised Visitation and Safe Exchange program 3843 W. 63rd Street,; Chicago, IL 60629; Telephone: (773) 884-3310; Fax: (773) 884-0003 Mujeres Latinas en Acción; Supervised Visitation and Safe Exchange program 1823 W. 17th Street; Chicago, IL 60602; Telephone: (773) 890-7676; Fax: (773) 890-7650 Other professional Supervisory Service __________________________________________________________________________ ________________________________________________________________________________________________________ B. SPECIAL CONSIDERATIONS Order of Protection Protected Party: ________________________________________ Order No. ______________________ Other: ________________________________________________________________________________________________ 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 Name: ___________________________________________ *Address: _________________________________________ _________________________________________________ Date of Birth: ______________________________________ Home Telephone No.: _______________________________ Work Telephone No.: ________________________________ Petitioner's Attorney Name: ___________________________________________ Address: __________________________________________ _________________________________________________ Telephone No.:_____________________________________ Fax: _____________________________________________ 4620 Supervised Visitation (* 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 Visitation 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: _____________________________________________ D. Suggested Schedule of Visits: Please indicate frequency, i.e. weekly or monthly Respondent's Attorney (Rev. 12/08/14) CCDR 0036 B Name: ___________________________________________ Address: __________________________________________ _________________________________________________ Telephone No.:_____________________________________ Fax: _____________________________________________ Other Attorney Name: ___________________________________________ Address: __________________________________________ _________________________________________________ Telephone No.:_____________________________________ Fax: _____________________________________________ ________________________________________________________________________________________________________ (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): _____________________________________________________________________ ________________________________________________________________________________________________________ Costs will be paid as follows: No Charge: 4386 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 referred agency within ten (10) days of the entry of this order and transmit all appropriate pleadings with this order within ten (10) days of the entry of this order: All parties shall promptly and
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