Supervised Visitation Checklist Form
Complete this checklist to document details and observations from a supervised visitation session.
Session Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervising Staff Name
*
First Name
Last Name
Child/Visitation Participant Name
*
First Name
Last Name
Visitation Location
*
Scheduled Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Scheduled End Time
*
Hour Minutes
AM
PM
AM/PM Option
Actual Arrival Time
*
Hour Minutes
AM
PM
AM/PM Option
Actual Departure Time
*
Hour Minutes
AM
PM
AM/PM Option
Observed Interactions (describe any notable interactions during the session)
Incidents/Concerns Noted and Overall Session Outcome
Submit Checklist
Should be Empty: