Submit an ApplicationLeave this field blankFirst NameLast NameYour Date of BirthStreet AddressCityPostal Code Indicate days you can be reached in morningsMondayTuesdayWednesdayThursdayFridayNot Available Indicate days you can be reached in afternoonsMondayTuesdayWednesdayThursdayFridayNot AvailableDo you consent for program staff to e-mail you?YesNoIf yes, what is your e-mail address?Do you consent for program staff to phone you?YesNoIf yes, what is your phone number?Do(es) the visiting child(ren) live with you?YesNoLanguages SpokenEnglishOther Do you require an interpreter?YesNoDo you require any accommodations? Have you had any involvement with a child protection agency?Previous involvement but the file is closedCurrent file open voluntarilyCurrent file open for investigationNoDo you or the other party have any current or pending criminal charges?Yes, I doYes, the other party doesYes, we both doNo Do you have any bail or probation conditions, no contact or restraining orders?Yes, I am on bailYes, I am on probationI have no contact conditions or a restraining orderNo Name of the other parent/partyChild(ren)'s InformationPlease add each child's information individuallyName of the visiting childChild's date of birthName of the visiting childChild's date of birthName of the visiting childChild's date of birthName of the visiting childChild's date of birthService DetailsService being requestedSupervised Parenting TimeExchangesBothIs there documentation that outlines the terms of the requested service?Yes, there is a court orderYes, there is a voluntary agreementNo Reason for Referral?Please select all that applyProlonged absence from the child(ren)Unresolved conflict between the partiesConcerns regarding parenting abilityChild abuse/neglectMental IllnessInterference with parenting timeConcerns regarding abductionDomestic violenceOtherSubmitConnect with a Starling Community Services consultantYesNoI am already connected with Starling Community Services
