* 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?


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?

* 12. If yes, non-profit agency or private provider?

* 13. If no, please describe your position:

* 14. Type of community-based nonprofit agency?
(Please check any that apply.)

* 15. Please check the type of services you provide:
(Please check any that apply.)

* 16. Type(s) of supervised visitation (SV) services:
(Please check any that apply.)

* 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.)

* 20. Single location or multiple sites?

* 21. In which counties and/or cities do you provide service?

* 22. Are you interested in becoming a member of CASVSP?

* 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:

T