Provider Information Sheet {RI-FL013}

SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE SUPERVISED VISITATION REFERRAL LIST PROVIDER INFORMATION CONTACT INFORMATION NAME OF PROVIDER: MAILING ADDRESS: CITY / STATE / ZIP TELEPHONE NO: FACSIMILE NO: WEBSITE ADDRESS: E-MAIL ADDRESS: GEOGRAPHICAL AREA(S) PROVIDER OFFERS SERVICE: TYPE OF SERVICE PROVIDED: (Check all that apply) Supervised Visitation Exchanges Supervised Exchanges Off-Site Visitation On-Site Visitation Phone Visitation Overnight Visits Travel and Extended Visits Arranged Other: _________________________________________________________ FEES: Intake Fee: $ ____________________ Hourly Fee: $ __________________ Sliding Scale No Yes (explain) _______________________________________ Other Fee Information: _________________________________________________ ADDITIONAL INFORMATION: (Areas of Specialty, Licenses, Certifications, Associations, Foreign Languages, etc.) I am registered with TrustLine ID#_____________________ I affirm that the above information is true and correct, and I have attached the declaration under penalty of perjury affirming I meet all of the standards set forth in Standard of Judicial Administration, 5.20 and Cal. Fam. Code § 3200.5. Print Name: _______________________ Date: ____________________________ Adopted for Mandatory Use Riverside Superior Court RI-FL013 [1/1/13] Signature: _________________________ PROVIDER INFORMATION SHEET riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com