Supervised visits shall be visit(s) per week of hours(s) each, to be arranged with the provider.
This form is attached to
Name of Protected Person:
Other Parent’s Name:
The Court Orders:
Parent to be supervised is:
Schedule of Supervised Visits
Type of Provider
Provider’s Information
Name:
Telephone number:
Costs Will Be Paid As Follows:
Contact With Provider
Judicial Council of California, www.courts.ca.gov
Rev. January 1, 2016, Mandatory Form
Family Code, § 3100, 3031
DV-150, Page 1 of 1
a.
b.
*If Other, specify relationship to child:
Address:
Supervised Visitation and Exchange Order
(Domestic Violence Prevention)
c.
Mediation, Visitation and Exchange
a.
b.
c.
Supervised Visitation and
Exchange Order
DV-150
Case Number:
Parties must go to mediation at:
Visitation of children is supervised.
Exchanges of children are supervised.
DV-110, Temporary Restraining Order DV-130, Restraining Order After Hearing
DV-140, Child Custody and Visitation Order
Mom Dad Other*
Mom Dad Other*
Mom Dad Other (name):
All visits as provided in the schedule on Form DV-140, item (d) are to be supervised.
Other schedule of supervised visits is attached. (Check here and attach a sheet of paper with “DV-150,
Other Schedule” for a title.)
a.
Professional (individual or supervised visitation center)
b.
Nonprofessional
Mom to pay: %
Dad to pay: %
Other:
8
Mom to contact provider before
(date):
Dad to contact provider before
Other:
4
1
4
2
3
5
6
7
9
The court also orders (specify):
This is a Court Order.
(date):
For your protection and privacy, please press the Clear
This Form button after you have printed the form.
