Visitor Form | Land Manor Wellness Centers

Visitor Acknowledgment Form

What is the name of the client you intend to visit?

Client First Name

Client Last Name

The following information is VISITOR (your) information:

Visitor First name

Visitor Last name

Visitor Email

Visitor Phone

Number of Visitors (No more than 4 visitors are permitted)

Please list the first and last name of ALL visitors over the age of 18

Date of Visit

Drug and Alcohol Free Visits

All visitors must arrive free from drugs and alcohol. If a visitor appears to be under the influence, they may be asked to take a drug or alcohol test. Refusing a test will result in the visit ending immediately. The most senior staff member on duty will determine whether testing is required and whether a visit must be terminated. Land Manor will always prioritize the safety of clients.

Visiting Hours

Visiting hours may change depending on facility needs. Visits may not begin before 1:00 PM and must end promptly at 5:00 PM.

Illness and Contagious Conditions

Visitors who have symptoms of a contagious illness (such as cold, flu, or similar conditions) should postpone their visit. Visitors who recently recovered from illness should take appropriate precautions to protect the health of clients.

Respectful Conduct

Violence of any kind—physical or verbal—will not be tolerated. Visits that become disruptive, agitated, or involve vulgar language or outbursts may be ended immediately.

Physical Contact

Excessive displays of affection, including prolonged kissing or inappropriate touching, are not allowed. Clients and visitors will receive one warning before a visit is terminated. Sexual contact of any kind is strictly prohibited.

Food and Beverages

Outside food and drinks are permitted only if purchased from a restaurant, fast-food establishment, or grocery store and remain in the original packaging. Homemade food or beverages are not allowed.

Photos and Video

Visitors may not take photos or videos of the facility or of any clients other than the individual they are visiting. Visitors must take care not to accidentally capture images of other clients.

Restricted Areas

Visitors are not permitted to enter private living areas, including client bedrooms or bathrooms. Visits may take place in approved areas such as group rooms, dining rooms, outdoor areas, or other designated common spaces.

Respect for the Community

Visitors are expected to remain respectful of clients, staff, and the facility’s buildings and grounds at all times.

Privacy and Confidentiality

Visitors must respect the privacy of all clients. Disclosing the identity of any client seen at the facility may violate federal privacy laws, including HIPAA, and may result in legal consequences.

If you have questions about visiting policies, please contact Land Manor before your visit.

I certify that I have watched and understand the orientation video and agree to follow the rules listed above. I understand that failure to comply may result in the termination of my visit and the loss of future visitation privileges.

Yes

No

Signature

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Date Signed

Month

Day

Year