Client Registration


Read below before filling out this registration form!

This form is meant for existing clients or individuals undergoing the intake process at the Heaven’s House facility. If you are in need of supervised visitation and exchange services then you need to contact our office to schedule an intake. It is important for you to understand that by filling out this form without undergoing an intake/orientation does not mean Heaven’s House is going to¬†provide you with the services you are seeking. Every party involved must complete an intake before services are granted.

Because we care about the safety of your personal files this registration form requires that you pick a strong password in order to submit it. Our website is certified safe through McAfee Secure.

Contact Name is required

Invalid Email, proper format “name@something.com”
Email is required


Select which service you require through Heaven’s House


Services needed is required


Current Address is required


00/00/000 format


Your Date Of Birth is required


Drivers License Number is required


Minor Child(ren)’s Last Name is required


List the child(ren) first and last names involved in the court action from oldest to youngest. Include Birthdays.


Children is required


Are you the Custodial or Non-Custodial Parent/Gaurdian? is required


Is there a Restraining Order? is required


Are there sexual abuse allegations? is required


Can be found on your court documents…


If you have an attorney please list their name, phone number, e-mail, and the paralegal assigned to your case. If you don’t have all this information supply what you do know. For no attorney type Pro Per.


If there has been a minors counsel assigned to the case please supply their name here


Username is required

Password is required

Confirm Password is required
>> HINT: The password should be at least seven characters long. To make it stronger, use upper and lower case letters, numbers and symbols like ! ” ? $ % ^ & ).

 

 
Check to Enable

 

Terms/Conditions

Terms/Conditions is required