FL-341(A)
CASE NUMBER:
PETITIONER/PLAINTIFF:
OTHER PARENT/PARTY:
RESPONDENT/DEFENDANT:
SUPERVISED VISITATION ORDER
Attachment to Child Custody and Visitation (Parenting Time) Order Attachment (form FL-341)
1.
abduction of child(ren)
sexual abuse
physical abuse
domestic violence
drug abuse
alcohol abuse
neglect
(specify):
other
2.
The court finds, under Family Code section 3100, that the best interest of the child(ren) requires that visitation by
THE COURT MAKES THE FOLLOWING ORDERS
3.
CHILD(REN) TO BE SUPERVISED
Child's Name SexAgeBirth Date
4.
TYPE
a.
Supervised visitation
b.
Supervised exchange only
5.
SUPERVISED VISITATION PROVIDER
a.
Professional (individual provider or supervised visitation center)
b.
Nonprofessional
6.
AUTHORIZED PROVIDER
Name TelephoneAddress
Any other mutually agreed-upon third party as arranged.
7.
DURATION AND FREQUENCY OF VISITS (see form FL-341 for specifics of visitation):
8.
PAYMENT RESPONSIBILITY % % %
Petitioner:
Respondent:
9.
Petitioner will contact professional provider or supervised visitation center no later than
(date):
Respondent will contact professional provider or supervised visitation center no later than
(date):
THE COURT FURTHER ORDERS
10.
Page 1 of 1
SUPERVISED VISITATION ORDER
Family Code, §§ 3100, 3031
www.courts.ca.gov
Date:
JUDICIAL OFFICER
Form Adopted for Mandatory Use
Judicial Council of California
FL-341(A) [Rev. January 1, 2015]
Evidence has been presented in support of a request that the contact of
with the child(ren) be supervised based upon allegations of
Petitioner Respondent
Other Parent/Party
disputes these allegations and the court reserves the findings on
these issues pending further investigation and hearing or trial.
Petitioner
Respondent Other Parent/Party
must, until further order of the court, be limited to contact
supervised by the person(s) set forth in item 6 below pending further investigation and hearing or trial.
Petitioner Respondent Other Parent/Party
Other Parent/Party:
Other Parent/party will contact professional provider or supervised visitation center no later than
(date):
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