Supervised Visitation Agreement Template

This Supervised Visitation Agreement (the “Agreement”) is made as of [Effective Date] by and between:

Parent A: [Full Name], address: [Address]

Parent B: [Full Name], address: [Address]

Child(ren): [Name(s), DOB(s)]

Case/Court (Optional): [Court/County], Case No. [__]

Existing Order (If Any): [Date] (if applicable)

1. Purpose and Status

1.1 The Parents agree to supervised visitation terms to support the child’s safety and well-being.

1.2 This Agreement is intended to be: ☐ temporary ☐ ongoing ☐ subject to court approval (if required).

1.3 This Agreement does not modify any protective order or existing court order unless approved by the court.

2. Supervisor

2.1 Supervisor is: ☐ professional visitation center ☐ agreed third-party adult.

2.2 Supervisor Name/Organization: [Name]

2.3 Contact: [Phone/Email]

2.4 Location: [Address]

2.5 Supervisor must be: ☐ neutral ☐ trained (if professional) ☐ approved by both parents (or court).

2.6 Supervisor may end a visit if safety concerns arise: ☐ Yes ☐ No (if “No,” explain).

3. Schedule

3.1 Supervised visits will occur:

• Day(s): [Days]

• Time: [Start–End]

• Frequency: [Weekly/biweekly/etc.]

• Start date: [Date]

Day(s): [Days]

Time: [Start–End]

Frequency: [Weekly/biweekly/etc.]

Start date: [Date]

3.2 Missed visits: [Make-up rules].

3.3 Cancellations require [__] hours’ notice except emergencies.

4. Location and Transportation

4.1 Visits will occur at: ☐ supervisor facility ☐ public location approved by supervisor ☐ other: [__].

4.2 Transportation and exchange:

• Drop-off by: ☐ Parent A ☐ Parent B ☐ supervisor/center

• Pick-up by: ☐ Parent A ☐ Parent B ☐ supervisor/center

  4.3 Parents will not have direct contact at exchange: ☐ Yes ☐ No (if “No,” rules: [__]).

Drop-off by: ☐ Parent A ☐ Parent B ☐ supervisor/center

Pick-up by: ☐ Parent A ☐ Parent B ☐ supervisor/center

4.3 Parents will not have direct contact at exchange: ☐ Yes ☐ No (if “No,” rules: [__]).

5. Rules During Visits

5.1 No alcohol or drugs during or within [__] hours before visits.

5.2 No weapons.

5.3 No threats, intimidation, or physical discipline.

5.4 No negative comments about the other parent or discussing adult legal issues with the child.

5.5 Photos/videos: ☐ allowed ☐ not allowed ☐ only with supervisor approval.

5.6 Gifts/food: ☐ allowed ☐ not allowed ☐ limited: [Rules].

5.7 Phone calls/video calls (optional): [Rules].

6. Costs (If Professional)

6.1 Supervision fees: $[**] per hour/session.

6.2 Paid by: ☐ Parent A ☐ Parent B ☐ split [**]% / [__]%.

6.3 Payment due: [Due date/method].

6.4 Nonpayment may result in cancellation subject to center rules.

7. Reports and Confidentiality (Optional)

7.1 Supervisor reports: ☐ none ☐ written notes to parents ☐ reports to court (if ordered).

7.2 Confidentiality: [Limits; court order controls].

8. Review and Transition Plan (Optional)

8.1 This Agreement will be reviewed on [Date] or after [__] visits.

8.2 Transition to unsupervised visitation may occur if: [Conditions], subject to court approval if required.

9. Disputes and Changes

9.1 Changes must be in writing and agreed by both parents (and supervisor/center if applicable).

9.2 Disputes: ☐ mediation ☐ parenting coordinator ☐ court.

Signatures

Parent A: [Full Name]

Date: [Date]

Signature: ___________________________

Parent B: [Full Name]

Date: [Date]

Signature: ___________________________

Supervisor (Optional Acknowledgment): [Name/Organization]

Date: [Date]

Signature: ___________________________