Santa Clara — FM-1179*

Source: https://santaclara.courts.ca.gov/system/files/forms/fm-1179_rem.pdf

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA

Family Court Services

Professional Supervised Visitation Provider List

Initial and Annual Renewal Application and Change Request Form

Updates to the FCS Professional Supervised Visitation Provider List will be made quarterly. Please indicate changes below.

New Provider Change Existing Provider Information Delete Provider

Name of Provider:

Doing Business As:

Address:

Phone: ( ) FAX: ( )

Email:

Web:

Areas Served:

Fees: Intake $_________

Regular Rate $__________ per/ ___________________________________

Sliding Scale Provided

Report fee $__________

Additional child charges $__________ per/ __________________________

Onsite Offsite Transportation Provided

Length of Visits: Minimum _____________ Maximum ____________

Hours: Mondays from _____to _____ Fridays from _____to _____

Tuesdays from _____to _____ Saturdays from _____to _____
Wednesday from _____to _____ Sundays from _____to _____

Thursday from _____to _____

Languages Provided: Supervised Exchanges Provided Exchanges Rate $

Related Services Offered:

FM-1179 REV Professional Supervised Visitation Provider List Page 1 of 2 01/01//2022 For Mandatory Use Initial and Annual Renewal Application and Change Request Form

California Standards of Judicial Administration (Uniform Standards of Practice for Providers of Supervised Visitation) Standard 5.20 and California Family Code Section 3200.5 set forth and defines the standards of practice, including duties and obligations for professional providers of supervised visitation.

Please initial confirming the following:

1. I meet the qualifications set forth and defined in California Family Code Section 3200.5 and
California Standards of Judicial Administration 5.20
_______

2. I have submitted my signed Judicial Council Form FL-324 (P) attached to this Form FM-
1179.
_______

I hereby declare under penalty of perjury under the laws of the State of California that by my initials set forth above, the information is true and correct.

SIGN

Date Signature

Please send the completed original form to:
Director of Family Court Services
Superior Court of California, County of Santa Clara
191 North First Street
San José, CA 95113

FM-1179 REV Professional Supervised Visitation Provider List Page 2 of 2 01/01/2022 Initial and Annual Renewal Application andFor Mandatory Use Change Request Form