STANDARD 5.20 TRAINING - May31-Jun2 2013 * 1. Business / Organization Name: * 2. Name: * 3. Mailing Address: * 4. City * 5. State: * 6. Zip Code: * 7. Email Address: * 8. Telephone: * 9. FAX: * 10. Are you from a supervised visitation agency? Yes No Under Standard 5.20 of the California Rules of Court, a professional provider is paid for providing supervised visitation services, or an independent contractor, employee, intern, or volunteer operating independently through a supervised visitation center or agency. * 11. Are you a professional provider? Yes No * 12. If yes, non-profit agency or private provider? 501(c)3 Non-profit agency Private provider * 13. If no, please describe your position: * 14. Type of community-based nonprofit agency?(Please check any that apply.) Child Abuse Domestic Violence Mental Health Alcohol/Substance Abuse Counseling Foster Care Other (please specify) * 15. Please check the type of services you provide:(Please check any that apply.) Supervised Visitation Supervised Exchange * 16. Type(s) of supervised visitation (SV) services:(Please check any that apply.) One-to-One Visitation Facilitated/Supportive Visitation Therapeutic Visitation Group (multiple families) Visitation Other (please specify) * 17. Family to SV Provider ratio, or average case load? * 18. Number of years providing service? * 19. Other service types provided?(Please check any that apply.) Parent education Counseling Batterer's treatment Support groups Alcohol/substance abuse treatment Mental health services Other (please specify) * 20. Single location or multiple sites? Single Location Multiple Sites * 21. In which counties and/or cities do you provide service? * 22. Are you interested in becoming a member of CASVSP? Yes No * 23. What would you like to accomplish as a result of the three-day training? * 24. State or identify one burning supervised visitation issue or question regarding Standard 5.20 that you would like to have addressed at the training? * 25. Please enter any comments or questions: Submit