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SUPERVISED ACCESS EXIT FORM

1.This exit form is being completed by the:
2.Name Of Centre:
3.Location :
4.Current Marital Status:
5. Date of last visit/exchange while in the program
6.Termination of services requested by:
7.Reason for program termination:
8.New access arrangements made:
9.Satisfaction of party with: Hours of Service
10.Satisfaction of party with: Facilities and Equipment
11.Satisfaction of party with: Neutrality of service         
12.Satisfaction of party with: Safety of the Environment for the Child
13.Satisfaction of party with: Safety of the Environment for Self
14.Satisfaction of party with: Restriction of visits to the site of the program
15.Satisfaction of party with: Cost of service (if applicable)
16.Satisfaction of party with: Staff
17.Satisfaction of party with: Distance to program
18.Satisfaction of party with: Provision of reports describing visits
19.Satisfaction of party with: Visiting in a group setting
20.Satisfaction with the supervision of visits : were the visits (please check one):
21.What other services (relevant to access) have you accessed in the past or are you using now? what other services would you like to use for yourself/ your children?
Past/Present    
Future
Group counselling                                           
Individual counselling                                     
Dispute mediation                                           
Family therapy                                                 
Parenting classes
Assessment
Legal and clinical services
Support Group  
22.Please write down any other comments you have regarding the Supervised Access Program: