Through the Vale Visitation & Family Services

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

Billing Authorization

County Responsible for Payment

Contact Name (if applicable)

Phone Number

Email for Invoices

Billing Notice:

In-Person supervised visitation services are billed with a two (2) hour minimum per visit. Virtual supervised visitation is billed with a one (1) hour minimum per visit. Billable time includes direct supervision, required documentation, and case-related service activities. Travel time, when applicable, is billed separately. Visits are billed from the scheduled start time, and the two-hour minimum remains applicable in cases of late arrival, early departure, or partial attendance.

Rates for Service:

Initial intake $80.00 (per party)

Supervised Visitation in-person (up to 4 children) $65.00 (per hour)

Supervised Visitation off-site (up to 2 children) $75.00 (per hour)

Supervised Visitation via Zoom (up to 4 children) $65.00 (per hour)

Supervised Exchange (up to 3 children) $30.00 (per exchange)

Travel Time $40.00 (per hour)

Case Information

County Case Number

Assigned Judge or Mediator

Is the visitation court ordered?

Yes

Unknown or Pending

Party(s) Referred for Supervision

Name

Relationship to the Child(ren)

Phone Number

Name

Relationship to the Child(ren)

Phone Number

Name

Relationship to the Child(ren)

Phone Number

Name

Relationship to the Child(ren)

Phone Number

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

Non-Familial Foster

Relative/Family

Other

Primary Caregiver Name

Phone Number

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)

Proposed Schedule (if known)

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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