Overnight Visitor Request

 

 

Full Name: Text field Date of request: Date

Phone Number:

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Child’s Name:

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Age:

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Date of Visit: Date

Time of Arrival: Text field CheckboxesCheckboxes

Departing Date: Date

Departing Time: Text field CheckboxesCheckboxes

Potential Triggers or Concerns:
1. Text field

2. Text field

3. Text field

Space for more potential triggers:

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(Examples: Loud noises, large crowds, certain locations or people, emotional stressors)

Coping Strategies/Plan:

1. Text field

2. Text field

3. Text field

Space for more strategies/plan:

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(Examples:
Bring a comfort item for the child, such as a favorite toy or blanket.
Plan quiet, calming activities such as reading a book or playing a game together.
Have a list of calming techniques, like deep breathing exercises or listening to calming music.)

Steps to Take in an Emergency:
Remove yourself and your child from the triggering situation.
Contact your emergency contact immediately.
Go to a safe location like a hospital or a police station if necessary.
Add three more examples specific to this vist:

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2. Text field

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Emergency Contacts:

Primary Contact Name:

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Relationship:

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Phone Number:

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Secondary Contact Name:

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Relationship:

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Phone Number: Text field

 

Signature: Signature

Date: Date

Reminders:

Immediately inform the house manager of any changes to visit details.

Contact the house manager promptly in case of any issues or delays.

Strict adherence to the safety plan is required.

Submit all requests at least 48 hours in advance.

Overnight visits are only allowed for children aged 10 or younger to ensure the safety of all house members and the children. 

 

Once submitted the house manager and director will review request and let you know if it is approved or not.