This is a Court Order.
Supervised Visitation and
This form is attached to
Mom Dad Other*
Name of Protected Person:
Mom Dad Other*
Other Parent’s Name:
The Court Orders:
Mom DadParent to be supervised is: Other (name):
Schedule of Supervised Visits
All visits as provided in the schedule on Form DV-140, item (d) are to be supervised.
Supervised visits shall be visit(s) per week of hours(s) each, to be arranged with the provider.
Type of Provider
a. Professional (individual or supervised visitation center)
Costs Will Be Paid As Follows:
Mom to pay:
Dad to pay:
Contact With Provider
Mom to contact provider before (date):
Dad to contact provider before (date):
Judicial Council of California, www.courts.ca.gov
Rev. January 1, 2012, Mand atory Form
Family Code, § 31 00, 3031
DV-150, Page 1 of 1
(Domestic Violence Prevention)
The court also orders (specify):
DV-110, Temporary Restraining Order DV-130, Restraining Order After Hearing
*If Other, specify relationship to child:
DV-140, Child Custody and Visitation Order
Therapeutic (licensed mental health professional)
Supervised Visitation and Exchange Order
Other schedule of supervised visits is attached. (Check here and attach a sheet of paper with “DV-150,
Other Schedule” for a title.)
Exchanges of children are supervised.
Mediation, Visitation and Exchange
Visitation of children is supervised.
Parties must go to mediation at:
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