Step 1 · Questionnaire

Start Supervised Parenting Time

Complete the questionnaire for FairPlay to review service fit. The questionnaire is not the intake. Submission does not guarantee acceptance of services.

Begin Step 1 - Complete Questionnaire

Before You Begin

How Intake Works

FairPlay’s intake process is more than administrative registration. Before services begin, the applicable court orders, safety concerns, logistics, scheduling needs, and FairPlay Rules and Guidelines are reviewed so clear expectations can be established.

1
A parent or attorney contacts FairPlay
Each prospective client or their attorney should contact FairPlay directly so the intake path is clear and neutral.
2
Each parent receives the same intake information
Each parent completes a separate questionnaire and contacts FairPlay directly to arrange their intake after service fit is confirmed.
3
Submit the questionnaire and governing documents
Each parent submits the completed questionnaire with a copy of the current court order.
4
FairPlay reviews service fit and availability
We review the materials, location, requested schedule, child needs, and supervisor availability. If appropriate, FairPlay provides the intake packet for review before all parties agree to proceed.
5
Separate parent intakes are scheduled
Once all parties agree to proceed and the intake fee is received, FairPlay conducts a separate one-hour phone intake with each parent and reviews the case history, documents, rules, guidelines, policies, and protocols.
6
The assigned supervisor prepares for parenting time
The supervisor conducts a brief Zoom or FaceTime meet-and-greet with the child and contacts each parent to coordinate logistics and plan visits.

Intake Overview

How the Questionnaire Is Used

The questionnaire collects information for the initial service-fit review. Services cannot begin until the separate one-hour telephone intake with each parent and required planning are complete.

What This Questionnaire Captures

Case Identification

Name, date of birth, court and docket number, judge, legal and physical custody, and individuals named on the order.

Legal & Safety Constraints

No-contact or restraining orders, minimum distance requirements, driving privileges, approved attendees, and phone or FaceTime permissions.

Visit Structure

Length and frequency of visits and any exchange-related limitations, where applicable.

Professionals Involved

Attorneys, Guardian ad Litem, parenting coordinator, parent and child therapists, and DCF contacts.

Child Safety & Care

Allergies, medical conditions, medications, special needs, and required accommodations.

Emergency Planning

Emergency contact information and protocols.

Clarification of Use

This questionnaire is used for intake, individualized planning, and service fit.

This is not:

An evaluation
A report
A recommendation
A therapeutic or forensic assessment

Information is handled according to FairPlay’s privacy practices and applicable legal requirements. Please submit only information relevant to the requested service.

Professional Practice Framework

FairPlay’s intake is informed by the 2023 Massachusetts Guidelines for Professional Parenting Time Supervisors and by the practice’s defined, non-evaluative service role.

Service Fit Determination

FairPlay determines whether it can support the requested parenting time based on the governing order or agreement, family needs, location, supervisor availability, and service scope.

Parents’ Information

FAIRPLAY PARENTING EDUCATION
FAIRPLAYEDU@YAHOO.COM | (978) 562-8601

This questionnaire is used solely to determine whether FairPlay Parenting Education is an appropriate service provider for your case. Submission does not guarantee acceptance of services.

Please return this form with a copy of the current court order and the name of the referring professional or previous supervisor, if applicable. Each parent completes a separate questionnaire. For voluntary accompanied parenting time without a court order, contact FairPlay to confirm the appropriate documents before submitting.

Case IdentificationSection A

Your Full Legal Name *Please complete this field.

Date of Birth *Please complete this field.

Home Address *Please complete this field.

EmployerPlease complete this field.

Usual working hoursPlease complete this field.

Preferred Phone Number *Please complete this field.

Email Address *Please complete this field.

Court *Please complete this field.

Case / Docket Number *Please complete this field.

JudgePlease complete this field.

Who has Legal Custody *Please complete this field.

Who has Physical Custody *Please complete this field.

Names of all individuals identified in the court orderPlease complete this field.

Name of referring professional or previous supervisor (if applicable)Please complete this field.

Legal & Safety ConstraintsSection B

Is there a restraining order in place? *

Yes No

Please choose an answer.

Non-custodial parent driving privileges (as defined by order/stipulation/agreement)Please complete this field.

Who may attend visits (list all permitted individuals)Please complete this field.

Phone / FaceTime permitted during visits? *

Yes No

Please choose an answer.

Are there any pending criminal charges or open investigations relevant to visitation safety? *

Yes No

Please choose an answer.

Do you own firearms? *

Yes No

Please choose an answer.

Visit Structure, Location & Community SettingSection C

Requested length and frequency of visits *Please complete this field.

Requested visit type *

In the community In the parent's home Other

Please choose an answer.

Town / City *Please complete this field.

Distance from child’s primary residencePlease complete this field.

Specific location(s) proposed (library, park, school, mall, etc.)Please complete this field.

Are these locations consistent with the court order? *

Yes No

Please choose an answer.

Preferred Days / TimesPlease complete this field.

Type of Service Requested

Supervised Parenting Time Accompanied Parenting Time Supervised Exchange Supervised Parenting Time and Supervised Exchange

Professionals & Supports InvolvedSection D

Your AttorneyPlease complete this field.

Attorney Email / PhonePlease complete this field.

Guardian ad litemPlease complete this field.

GAL Email / PhonePlease complete this field.

Parenting CoordinatorPlease complete this field.

Other Professional Supports (therapist, counselor, coach, caseworker)Please complete this field.

Child’s Therapist(s)Please complete this field.

DCF Office (if applicable)Please complete this field.

DCF Ongoing WorkerPlease complete this field.

DCF SupervisorPlease complete this field.

Child Safety, Care & Visit PreparationSection E

Complete for EACH child.

Child 1

Child’s Name *Please complete this field.

AgePlease complete this field.

Date of Birth *Please complete this field.

Child’s interests / preferred activitiesPlease complete this field.

Special needs / required accommodationsPlease complete this field.

Allergies (food/environment/medication)Please complete this field.

Documented food restrictions or dietary issuesPlease complete this field.

Medical conditions (if any)Please complete this field.

Medications (if any)Please complete this field.

Known fears, triggers, or sensitivities (for safety planning only)Please complete this field.

Date child last saw the parent requesting visitsPlease complete this field.

Date child last spoke with the parent requesting visitsPlease complete this field.

Emergency ContactsSection F

Emergency Contact Name *Please complete this field.

Emergency Contact Phone Number *Please complete this field.

Service Fit & Availability

FairPlay Parenting Education reserves the right to determine whether it is able to support the family based on:

Safety considerations
Geographic location
Supervisor availability
Alignment with FairPlay protocols

Submission of this questionnaire does not guarantee agreement to provide services.

Parent’s Acknowledgments

Each acknowledgment is required.

I understand that FairPlay Parenting Education does not provide reports, opinions, evaluations, or recommendations to the court or to any party. I understand that FairPlay supervisors may intervene at any time to maintain safety, reduce intimidation, and ensure compliance with FairPlay rules, guidelines, and protocols. I understand that FairPlay supervisors are not mediators, arbitrators, therapists, Guardians ad Litem, or parenting coordinators, and cannot modify custody or parenting plans. I understand that any changes to visitation must occur by written agreement, stipulation, or court order.

Acknowledgments Regarding Setting

I understand that FairPlay Parenting Education does not support exchanges at police stations. I understand that professional supervisors are present in all community settings and FairPlay protocols are used (libraries, schools, grocery stores, Target, parks, etc.) when appropriate and consistent with the court order. I understand that FairPlay seeks to avoid unnecessary association of parenting time with law-enforcement environments. I understand that police stations may expose children to unrelated high-risk public situations. I understand that a FairPlay supervisor may intervene at any time to maintain safety and protocol compliance. I understand that transporting a supervisor in my vehicle requires court authorization, stipulation, or written agreement, and supervisor sits in front passenger seat with children properly secured in back.

Signature & Court Order

Typed Full Legal Name *Please complete this field.

Date *Please complete this field.

I intend my typed full legal name and date to serve as my electronic signature on this questionnaire.

Current Court Order *Please complete this field.

Attach the current court order. Combined attachments must be 10 MB or smaller. If you cannot attach it, contact FairPlay to arrange submission before completing this form.

Please complete the required fields, acknowledgments, signature, and court-order upload.

Required fields are marked *. Your questionnaire and attachments are sent to FairPlay through FormSubmit. Privacy practices.

Start Supervised Parenting Time

How Intake Works

A parent or attorney contacts FairPlay

Each parent receives the same intake information

Submit the questionnaire and governing documents

FairPlay reviews service fit and availability

Separate parent intakes are scheduled

The assigned supervisor prepares for parenting time

How the Questionnaire Is Used

What This Questionnaire Captures

Case Identification

Legal & Safety Constraints

Visit Structure

Professionals Involved

Child Safety & Care

Emergency Planning

Clarification of Use

Professional Practice Framework

Service Fit Determination

Parents’ Information

Child 1

Acknowledgments Regarding Setting