I certify that the information provided in this form is true and complete to the best of my knowledge. I understand that this intake form is used to determine eligibility and appropriateness for services offered by Secure Family Visits Inc. I authorize Secure Family Visits Inc. to contact me, review the information provided, and communicate with the other parent or legal parties as needed to coordinate services. By checking this box and typing my name below, I affirm that this submission constitutes my voluntary electronic signature.