Free CCDR 0036 5-18-07.pmd - Illinois

Supervised Visitation Order-Agency Only IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION

(5/18/07) CCDR 0036 A

_____________________________________________________
Petitioner v.

_____________________________________________________
Respondent

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No. _______________________________________

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, and this court having jurisdiction over the subject matter, by agreement after hearing, Petitioner Respondent Other shall have
(Name(s) of Child(ren))

IT IS HEREBY ORDERED that the A. 4620 Supervised Visitation

Safe Exchange with ___________________________________________________________

at (agency checked below is the preferred provider) Apna Ghar, Supervised Visitation and Safe Exchange program 4753 N. Broadway, Suite 632, Chicago, IL 60602 Telephone: (773) 334-0173 Fax: (773) 334-0963 The Branch Family Institute, Supervised Visitation and Safe Exchange program 3139 W. 111th Street, Chicago, IL 60655 Telephone: (773) 238-1100 Fax: (773) 238-4095 Mujeres Latinas en Acción, Supervised Visitation and Safe Exchange program 1823 W. 17th Street, 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) Reside(s)

_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Mother: Name: ____________________________________________ Address*: _________________________________________ Mother's Attorney: Atty. No. _______________ Name: _______________________________________________ Address: _____________________________________________

_________________________________________________ Date of Birth: ______________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________

____________________________________________________ Telephone: ____________________________________________ Fax: _________________________________________________
(OVER)

(*If party has not disclosed an address, that party shall designate an alternative address for the purpose of notice.)

(5/18/07) CCDR 0036 B Father: Name: ____________________________________________ Address*: _________________________________________ Father's Attorney: Atty. No. _______________ Name: _______________________________________________ Address: _____________________________________________

_________________________________________________ Date of Birth: ______________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________
Other: Name: ____________________________________________ Address*: _________________________________________

____________________________________________________ Telephone: ____________________________________________ Fax: _________________________________________________
Other's Attorney: Atty. No. _______________ Name: _______________________________________________ Address: _____________________________________________

_________________________________________________ Date of Birth: ______________________________________ Telephone (H): _____________________________________ Telephone (W): _____________________________________
Child's Representative/Guardian ad Litem/Attorney for Child Atty. No. _______________ Name: ____________________________________________ Address: __________________________________________

____________________________________________________ Telephone: ____________________________________________ Fax: _________________________________________________

_________________________________________________ Telephone: ________________________________________ Fax: _____________________________________________
D. Suggested Schedule of Visits:

_____________________________________________________________________________ _____________________________________________________________________________________________________
(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 Payment is ordered as follows (%): ___________________________________________

G. Contact with provider: Mother to contact provider before (date): ___________________________, __________. Father to contact provider before (date): ___________________________, __________. H. This matter is set for status on _____________________________, __________ at ______________ m. in Room ___________. I. The attorney for _______________________________________ shall contact the the referred agency within 10 days of the entry of this order and transmit all appropriate pleadings with this order within 10 days of the entry of this order. All parties shall promptly and fully comply with the requirements of any referring agency. ENTERED:

Atty. No. _______________ Name: ________________________________________________ Atty. for: _____________________________________________ Address: _______________________________________________ City/State/Zip: ________________________________________ Telephone: ____________________________________________ Fax: ________________________________________________

Dated: _________________________________, ___________

__________________________________________________
Judge Judge's No.

(*If party has not disclosed an address, that party shall designate an alternative address for the purpose of notice.) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS