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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 1/8/2013

Supervised Visitation Order - Agency Only IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION Print Form Clear Form (12/06/12) CCDR 0036 A ________________________________________________________________ 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, 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 Other shall have 4620 Supervised Visitation Safe Exchange with _________________________________________________________________ at Name(s) of Child(ren) (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 West 17th St., Chicago, IL 60608; 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) Resides _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Petitioner: Name: _____________________________________________ Address*: __________________________________________ Petitioner's Attorney: Name: _____________________________________________ Address: __________________________________________ ___________________________________________________ Date of Birth: ______________________________________ Telephone (H): ______________________________________ Telephone (W): ______________________________________ _________________________________________________ Date of Birth: ______________________________________ Telephone: ________________________________________ Fax: _______________________________________________ (Page 1 of 2) (*If party has not disclosed an address, that party shall designate an alternative address for the purpose of notice) (12/06/12) CCDR 0036 B Respondent: Name: _____________________________________________ Address*: __________________________________________ Respondent's Attorney: Name: _____________________________________________ Address: __________________________________________ ___________________________________________________ Date of Birth: ______________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________ Other: Name: _____________________________________________ Address*: __________________________________________ _________________________________________________ Telephone: ________________________________________ Fax: _______________________________________________ Other Attorney: Name: _____________________________________________ Address: __________________________________________ ___________________________________________________ Date of Birth: ______________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________ Child's Representative/Guardian ad Litem/Attorney for Child: Name: _____________________________________________ Address*: __________________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________ _________________________________________________ Telephone: ________________________________________ Fax: _______________________________________________ D. Suggested Schedule of Visits: Please indicate frequency, i.e. weekly or monthly _______________________________________________________________________________________________________________________ (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: 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 10 days of the entry of this order and transmit all appropriate
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