Fill and Sign the Request for Referral to Parental Access Program and Treatment Programs Oregon Form

Parental Access and Visitation Program P.O. Box 12869, Salem, OR 97309 Marion County Courthouse, Fourth Floor (503) 589-3230 100 High St. NE, Salem, Oregon Request for Referral to Parental Access Program ________________________________________________________________________ Petitioner’s Name Respondent’s Name Case No. ______________Reason for Referral:_________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ The parties have agreed to participate in the following parts of the program:  Supervised Visitation for  Petitioner  Respondent. Name (s) of child/ren: _______________________________________________________________________ Days and times: ________________________________________________________________________ ________________________________________________________________________  Supervised Exchanges (available Wednesday, Friday, and Sunday evenings, exact times will be set by the service provider, Options). Name(s) of child/ren: ______________________________________________________  Random Substance Testing for  Petitioner  Respondent for the the following substances: ___________________________________________________________________ Testing should be required for a period of _____________________ weeks/months. Request for Referral to Parental Access Program; Treatment Programs1  Treatment/Intervention for:  Substance Abuse (treatment will only be required in accordance with the initial substance abuseassessment)  Domestic Violence  General Violence Please check which treatment/intervention program you would like to be referred to on the back of this form. If you don’t specify one, the court will choose one for you. I understand that the information contained in this form is not confidential and will be reviewed by the court. By signing this form, I am asking that the court enter an order referring my case to the Parental Access and Visitation Program according to the selections indicated above. ___________________________________ ____________________________________ Petitioner Date Respondent Date Return form to Parental Access Program Request for Referral to Parental Access Program; Treatment Programs2 Treatment Programs 1. Substance Abuse.  Bridgeway  Network Behavioral Health  Inside Out Care  New Step Behavioral Health  Kaiser Permanente Recovery Resources  Seasons Counseling Center  Marion County Health Department  Serenity Lane  Stayton Counseling 2. Domestic Violence Intervention.  Solutions D.V.I.P.  The Decisions Program  24 Week (minimum) 24 Week (minimum) Offender Program Offender Program  48 Week (minimum) Offender Program (For repeat offenders) 3. General Violence Intervention.  CAL Violence Intervention  NTSI Aggression Control (48 hours/24 weeks) Level 1 (8 hours/1 day)  C&B Training Anger Management  NTSI Aggression Control (12 hours/8 weeks) Level 2 (16 hours/2 day) Request for Referral to Parental Access Program; Treatment Programs3