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Through the Vale Visitation & Family Services

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Agency Referral Form

This referral form is designed to provide our agency with the information needed to begin supervised visitation services. Please include any relevant court orders, placement information, and case details that will help ensure visits are structured safely and in accordance with court requirements. Our services are provided in alignment with California Rules of Court Standard 5.20 and focus on safety, neutral supervision, and objective documentation. For questions, please contact our office at info@throughthevale.com or (916) 360-0364.

Referring Agency Information

Referring Agency Name*

County*

Primary Point of Contact Name*

Title

Phone Number

Email

Billing Authorization

County Responsible for Payment*

Contact Name (if applicable)

Phone Number

Email for Invoices*

Case Information

County Case Number

Assigned Judge or Mediator

Is the visitation court ordered?

Yes

No

Unknown or Pending

Party(s) Referred for Supervision

Name*

Relationship to the Child(ren)*

Phone Number

Email

Name

Relationship to the Child(ren)

Phone Number

Email

Name

Relationship to the Child(ren)

Phone Number

Email

Name

Relationship to the Child(ren)

Phone Number

Email

Child(ren) Information

Name*

Date of Birth*

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

There are more than 5 children included in the order.

Current Placement Type*

Foster

Relative/Family

Other

Primary Caregiver Name

Phone Number

Email

Visitation Order

Frequency of Vsits

Length/Duration of Visits

Supervision Level

Line of sight & earshot

Monitored exchange/transition only

Other Requirements (please explain)

Special Conditions or Restrictions (if any):

No discussion of case/allegations

No photos/videos

No physical contact restrictions

Other Requirements (please explain)

Safety Considerations

Any known safety concerns, behavioral issues, or special needs we should be aware of?

Documents

Court Order

No Contact Order

Referring Party Signature

First name*

Last name*

Today's Date*

Signature*

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