* 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: