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CALIFORNIA COURTS SELF-HELP CENTER
www.courtinfo.ca.gov/selfhelp
INSTRUCTIONS: Form FL-341(A)
Supervised Visitation Order
This is an order.
This form is only used if one of the parents needs to have his or her
visits supervised by a third person.
FL-341(a) Instructions
A. Petitioner: I. 5. Information about visitation
• The name of the petitioner (usually supervisor:
your name). • Check box 5a if the person who will
B. Respondent: supervise the visitation is a
• The name of the respondent. professional supervisor.
C. Case number: • Check box 5b if the person is not a
• Always use the same case number professional supervisor (for example, a
that the court clerk assigned when family member or friend).
you started your case. J. 6. Information about supervisor:
D. 1. Why there should be supervised • Write the supervisor’s name, address,
visitation: and phone number.
• Check the box for the person who you K. 6. Other supervisor:
want to be supervised. • If you think you will sometimes want
• Check all the boxes that describe the someone else to supervise the
reason(s) for that person to have visitation, check this box. You
supervised visitation with the should only check this box if you
children. think you and the other parent will
• If you check the box marked “other,” agree to have someone else supervise
you must explain the reason. the visitation.
E. 1. Disputing allegations: L. 7. Duration and frequency:
• If the other parent disagrees with • Write how long (duration) each
what you are saying happened and the supervised visit will be. Write how
judge wants to hear more facts, the often (frequency) the other parent will
judge will check the appropriate box have visitation.
here. • This can also be left blank. The
F. 2. Who will have supervised visitation; visitation schedule is on Form FL-
• Check the box for the person who will 341.
be supervised. M. 8. Payment responsibility:
G. 3. Supervised visitation orders: • Write the portion of the cost of
• Write the name of each child who will supervision you will pay and what
have supervised visitation. Write portion the other parent will pay.
each child’s birth date, age, and sex. N. 9. Contacting supervisor:
Write F (for Female) for girls and M • Only check this box if you will be
(for Male) for boys. using a professional supervisor.
H. 4. Type of visitation: Otherwise, leave this blank.
• Check box 4a, “Supervised • Check the box saying if you will be
visitation,” for an order telling the the one to find and get in touch with a
other parent to spend time with the supervisor or if the other parent will
children only in the presence of a get in touch with the supervisor.
supervisor, (See G3, above.) • Write the date by which you or the
• Check box 4b, “Supervised exchange other parent will have contacted the
only,” for an order to have a supervisor.
supervisor present when you O. 10. Other orders:
exchange the child(ren) with the other • List any other conditions limiting
parent. supervised visitation here that you
• Check box 4c, “Therapeutic want the court to order.
visitation,” for an order that the other P. Signature of Judicial Officer and date:
parent see the children only during • This is for the judge to date and sign.
visits with a therapist, counselor,
social worker, psychologist, or
psychiatrist.
FL-341(a) Instructions
A B C
FL-341(A)
PETITIONER / PLAINTIFF: Pat Garcia CASE NUMBER:
RESPONDENT / DEFENDANT: Chris Jones
SUPERVISED VISITATION ORDER
Attachment to Child Custody and Visitation Order Attachment (form FL-341)
D 1. Evidence has been presented in support of a request that the contact of Petitioner X Respondent with the child(ren)
be supervised based upon allegations of
abduction of child(ren) physical abuse drug abuse neglect
sexual abuse X domestic violence alcohol abuse other (specify):
E
Petitioner Respondent disputes these allegations and the court reserves the findings on these issues pending further
investigation and hearing or trial.
F 2. The court finds, under Family Code section 3100, that the best interest of the child(ren) requires that visitation by
Petitioner X Respondent must, until further order of the court, be limited to contact supervised by the person(s) set
forth in item 6 below pending further investigation and hearing or trial.
THE COURT MAKES THE FOLLOWING ORDERS
G 3. CHILD(REN) TO BE SUPERVISED
Child's name Birth date Age Sex
Richard Jones November 26, 1994 8 years M
H 4. TYPE
a. Supervised visitation b. X Supervised exchange only c. Therapeutic visitation
I 5. SUPERVISED VISITATION PROVIDER
a. Professional (individual provider or supervised visitation center) b. X Nonprofessional
6. AUTHORIZED PROVIDER
Name Address Telephone
J
Melinda Jones 234 Maple Street, My Town, CA (555) 444-4321
K X Any other mutually agreed-upon third party as arranged.
7. DURATION AND FREQUENCY OF VISITS (see form FL-341 for specifics of visitation):
L
8. PAYMENT RESPONSIBILITY Petitioner: ______% Respondent: ______% n/a
M
9. Petitioner will contact professional provider or supervised visitation center no later than (date):
N Respondent will contact professional provider or supervised visitation center no later than (date):
O 10. THE COURT FURTHER ORDERS
Date:
P JUDICIAL OFFICER
Page 1 of 1
Form Adopted for Mandatory Use Family Code, §§ 3100, 3031
Judicial Council of California SUPERVISED VISITATION ORDER www.courtinfo.ca.gov
FL-341(A) [Rev. January 1, 2003]
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