Supervised Visitation is a structured, child-focused service facilitated by a licensed or otherwise appropriately qualified clinical professional. It is distinct from individual, family, and reunification therapy.

I authorize The Toby Center to exchange the minimum administrative information reasonably necessary to review this request, assign a therapist, coordinate scheduling and payment, verify attendance, and communicate with:

I understand that the approved hourly rate is based on the current fee schedule published on The Toby Center website, and that a separate intake/registration fee applies per participating parent or guardian. Payment must be completed through the online Client Payment Portal before service begins.

1. I request the service identified in this form and certify that the information provided is accurate to the best of my knowledge.
2. I understand that this document governs agency intake, coordination, scheduling, and payment; it is not the therapist's clinical informed-consent agreement.
3. I understand that the therapist will provide separate clinical, privacy, records, emergency, and treatment documents before clinical services begin.
4. I authorize the administrative information sharing selected above and understand that clinical disclosures require the therapist's separate process unless otherwise authorized or required.
5. I will provide current court orders, referral documents, payment information, safety information, and material changes affecting the service.
6. I understand the approved fee, advance-payment requirement, payment allocation, and cancellation policy.
7. I understand that placement depends on therapist availability, professional fit, authority to begin services, and the ability to provide the service safely and appropriately.
8. I understand that The Toby Center and the assigned therapist do not promise a particular court, custody, parenting-time, treatment, or family outcome.
9. I understand that failure to pay, repeated missed appointments, unsafe conduct, lack of required authorization, or refusal to follow applicable policies may delay, suspend, or end agency coordination.