Service Request Form Please complete this short form to request services from our Children’s Safe Exchange and Visitation program. Please enter your name:* Which services are you requesting?* Safe Exchange Monitored Visitation Both or Other Which location were you referred for services?* Lexington Georgetown Danville Please provide an email address that you check regularly. What is your phone number?*Do you prefer we contact you by email or phone? Email Phone Either is fine. Are you the custodial or non-custodial party?* Custodial Non-custodial Other or unsure How were you referred to our services?* Court DCBS Other What is your preferred spoken language?* English Spanish French Arabic Other What language do you speak?* Would you like us to use an interpreter when we call you?* Yes No Do you have other information to share?Please do not share confidential information through this form. Only use this space for short notes or other questions.PhoneThis field is for validation purposes and should be left unchanged.
