Supervised Visitation Intake Form

Emergency Assistanace

If this is an emergency, call:

9-1-1
Crisis Line: 9-8-8
National Suicide Prevention Lifeline: 1-800-273-8255
Maryland's Helpline: 2-1-1

Client Information

Representative Full Name

First Name

Last Name

Date of Birth

Gender

Phone Number

Email address

Address 1

City

State

Zip Code

Can we contact you by email or phone?

Phone Email Both

If no, what is your preferred method of communication?

Personal History

What is your highest level of education

Are you currently employed?

Yes No

If yes, what is your current occupation?

1. Do you use drugs?

Regularly Occasionally No

2. Do you smoke?

Regularly Occasionally No

3. Do you drink alcohol?

Regularly Occasionally No

4. Do you drink caffeine?

Regularly Occasionally No

5. Do you gamble?

Regularly Occasionally No

6. How often do you get a full night of sleep? 7-8 hours

Regularly Occasionally No

7. Do you exercise?

Regularly Occasionally No

8.Do you have a healthy and balanced diet?

Regularly Occasionally No

9. How often do you have time for fun and recreational activites?

Regularly Occasionally No

Is there anything else regarding your personal history that we should be aware of?

Emergency Contact

First Name

Last Name

Phone Number

Relationship

In case of an emergency, do we have permission to contact this person?

Yes No

Medical History

Have you previously received supervised visitation services

Yes No I can't remember

If yes, what is the supervisor or agency name?

Have you previously been prescribed psychiatric medication?

Yes No I can't remember

If yes, what medications are you currently taking?

Are you pregnant?

Yes No

If yes, how far along?

Is there anything else regarding your medical history that we should be aware of?

Family History

Is there anything regarding your relationships you would like us to be aware of?

Briefly describe your relationships with your parents

Is there anything else regarding your family history that we should be aware of?

Attach any important document E.g. restraining order etc.

Add file

Please upload a file

Reasons for Visit

Referral:

Court Ordered Supervised Visitation

Independent Supervised Visitation

Agency Referred

Attach any referral document E.g. Court Order

Add file

Please upload a file

Please enter custodial or visiting parent information:

Full Name

Phone Number

Email Address

How many children will be monitored?

*For Supervised/Therapeutic Visitation please enter each children info:

Please enter each children name and age

Describe the reasons you are supervised/therapeutic visitation.

Describe any goals or outcomes you hope to achieve from supervised/therapeutic visitation.

Describe any significant life changes or stressful events that you have recently experienced.

Is there anything else you'd like to tell us about?

Legal Representative Information

Current Judge In Your Case

Court Address

Your Attorney Full Name

Email Address

Phone Number

Opposing Attorney Full Name

Email Address

Phone Number

Scheduling Consultation Call with Baiden & Associates

Telehealth or In person? There is no fee for travel time or mileage under 50 miles (Downtown Silver Spring) round trip. Over 50 miles and not to exceed 100 miles round trip there is an additional $35.00 fee.

Telehealth In- Person

If court ordered, visiting parent will be required to provide court order document

Both Options

How many visits per week

1 X Week 2 X Week 3 or more

How many hours per visits?

2 Hours 3 Hours More than 3 hours

Location If court ordered, visiting parent will be required to provide court order document

Visiting Parent Home

Library

Community Center

Outdoor

Family Member Home

Payment Method

ACH Bank Transfer Master Card Visa Card Zelle Cashier Check

Payment Responsibility

Visiting Parent Custodial Parent Agency

Please verify below:

I verify that I am the person seeking services for myself or have legal authority to consent for a minor in my care.

I understand it is the policy of Baiden & Associates LLC to have consent from both parents before entering into services for a minor.

I understand, by law, I will need to produce court documents (as applicable in divorce, legal separation and/or custody agreement situations) indicating I have legal authority to enter a minor in my care into mental health services.

I understand that Baiden & Associates LLC do not accept forms of insurances payments but may also seek for slide scale fee

Your information will be encrypted.

Baiden & Associates LLC

Baiden & Associates LLC is the leading counseling and supervised visitation services in Maryland, Virginia, and Washington, D.C. We provide quality mental health care rooted in evidence-based practice, empathy, and respect for Individuals, couples, and families. Our experienced service providers will make you feel welcomed, understood, accepted, and empowered as you embark on your journey to a full and meaningful life.