Professional Supervised Visitation Provider List Initial and Annual Renewal Application {FM-1179}

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA Family Court Services Professional Supervised Visitation Provider List Information Inclusion and Change Request Form Updates to the FCS Professional Supervised Visitation Provider List will be made quarterly. Please indicate changes below. New Provider Name of Provider: Doing Business As: Address: Phone: ( Email: Web: Areas Served: Fees: Intake $__________ Regular Rate $__________ per/ ___________________________________ Sliding Scale Provided Report fee $__________ Additional child charges $__________ per/ __________________________ Onsite Offsite Transportation Provided ) FAX: ( ) Change Existing Provider Information Delete Provider Length of Visits: Minimum _____________ Maximum ____________ Hours: Mondays Tuesdays Thursday Languages Provided: Supervised Exchanges Provided Related Services Offered: Please send the completed original form to: Director of Family Court Services Superior Court of California, County of Santa Clara 191 North First Street San José, CA 95113 Exchanges Rate $ from _____to _____ from _____to _____ from _____to _____ Fridays from _____to _____ Saturdays from _____to _____ Sundays from _____to _____ Wednesday from _____to _____ FM-1179 REV 09/16/16 Professional Supervised Visitation Provider List Information Inclusion and Change Request Form American LegalNet, Inc. www.FormsWorkFlow.com