SO Informed Consent for Visitation with Minors

Client Information
Client name: IDOC#:
Conviction history:
Age of victim(s):
Person who has Legal Parental Rights
Statement of Understanding and Agreement
My Minor Child’s NameDate of BirthMy Minor Child’s NameDate of Birth
My Current Home Address: StreetCityStateZip
My Current Phone Numbers: HomeCellOtherIn preparation of‘s (hereinafter referred to as ‘the client’) contact with my minor child/children, I have been informed ofthe client’s conviction
history and the age of the victim(s). I understand that the client is in or has completed a treatment program and that although the client is involved in or successfully completedtreatment,it
is possible for the client to re-offend.I agree to help the client avoid anyphysical contact with my minor child/children. I also agree that under no circumstances will my minor child/children
ever be left alonewith the client (this includes being left alone in an automobile or room). Based on the information given to me about the client’s conviction history and the age(s)
of the victim(s), I hereby give my informed consent for my minor child/children to have supervised contact with the client. I understand that a copy of this form will be provided to
theclient’ssupervising probation and parole officer (PPO). Furthermore, I understand that this form does not give or imply permission for the client to have contact (supervised or unsupervised)
with any other minors. I also understand that any contact the client has with minors, including my minorchild/children, must be approved by the client’s supervising PPO and treatment
provider (if enrolled).This agreement is subject to the client’s compliance with probation/parole and can be revoked at any time by the child/children’s legal guardian or the probation
and parole office.
Parent’s Printed Name
Parent’s SignatureDate
IDOC ApprovalApproved Denied
PPO’s Printed Name
PPO’s SignatureDateApproved Denied
District Manager’s (or Designee’s) Printed Name
District Manager’s (or Designee’s) SignatureDateApproved Denied
Treatment Provider Printed Name
Treatment Provider’s SignatureDate