Form Pkt-008 - Domestic Violence - Restraining Order With Children Packet Page 8
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23Supervised Visitation and
Case Number:
DV-150
Exchange Order
This form is attached to
DV-110, Temporary Restraining Order
DV-130, Restraining Order After Hearing
DV-140, Child Custody and Visitation Order
Name of Protected Person:
Mom
Dad
Other*
1
Other Parent’s Name:
Mom
Dad
Other*
2
*If Other, specify relationship to child:
The Court Orders:
Mediation, Visitation and Exchange
3
a.
Parties must go to mediation at:
b.
Visitation of children is supervised.
Parent to be supervised is:
Mom
Dad
Other (name):
c.
Exchanges of children are supervised.
Schedule of Supervised Visits
4
a.
All visits as provided in the schedule on Form DV-140, item
(d) are to be supervised.
4
b.
Supervised visits shall be
visit(s) per week of
hours(s) each, to be arranged with the provider.
c.
Other schedule of supervised visits is attached. (Check here and attach a sheet of paper with “DV-150,
Other Schedule” for a title.)
Type of Provider
5
a.
Professional (individual or supervised visitation center)
b.
Nonprofessional
Provider’s Information
6
Name:
Telephone number:
Address:
Costs Will Be Paid As Follows:
7
Mom to pay:
%
Dad to pay:
%
Other:
Contact With Provider
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Mom to contact provider before (date):
Dad to contact provider before
(date):
Other:
The court also orders
(specify):
9
This is a Court Order.
DV-150,
Judicial Council of California,
Supervised Visitation and Exchange Order
Page 1 of 1
Rev. January 1, 2016, Mandatory Form
(Domestic Violence Prevention)
Family Code, § 3100, 3031
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