CME Referral Form

Referral for Child Medical Evaluation (CME) at SAFEchild Advocacy Center

2841 Kidd Road, Raleigh NC 27610
Your Email Address
ReferredBy@example.com
Referral Date

MonthDayYear
Referring Agency
Child Welfare & DCDEE
Child Welfare Agency/DCDEE also investigating/involved with CHILD/ CAREGIVER(s)
Child Welfare SIS# or DCDEE Case#
SIS# or CNDS#
Child Welfare Agency
Child Welfare Agency by NC County, NC DCDEE, or out-of-state agency
Social Worker

SW FirstSW Last
SW Mobile#
SW Mobile#Format: 000-000-0000.
SW Email
SW@example.com
SW Supervisor

SW Supv FirstSW Supv Last
SW Supervisor Mobile#
SW Supervisor Mobile#Format: 000-000-0000.
SW Supervisor Email
SWSup@example.com
Additional Child Welfare Agency, Social Workers, or DCDEE involved? (Ex: Foster Care Social Worker, DCDEE, etc.)
Additional Child Welfare Agency, Social Workers, or DCDEE
Additional Child Welfare Agency by NC County, NC DCDEE, or out-of-state Child Welfare Agency
Additional SW

Add SW FirstAdd SW Last
Additional SW Role
Add SW Role (ie - Investigator, Foster Care, etc.)
Additional SW Mobile#
AddSW Mobile#Format: 000-000-0000.
Additional SW Email
AdditionalSW@email.com
Additional SW Supervisor Name

AddSWsup FirstAddSWsup Last
Additional SW Supervisior Mobile#
AddSWsup Mobile#Format: 000-000-0000.
Additional SW Supervisor Email
AddSWSupervisor@example.com
Law Enforcement
Law Enforcement Agency also investigating/involved with CHILD/CARETAKER(s)
LE Agency
LE Agency
LE Title
LE Title (ie - Investigator, Detective, Sergeant, Special Agent, etc.)
LE Name

LE First NameLE Last Name
LE mobile#
LE mobile#Format: 000-000-0000.
LE Email
LE@email.com
LE Supervisor Title
LE Supervisor Title (ie - Investigator, Detective, Sergeant, Special Agent, etc.)
LE Supervisor

LEsup FirstLEsup Last
LE Supervisor Mobile#
LEsup Mobile#Format: 000-000-0000.
LE Supervisor Email
LESupervisor@email.com
Additional Law Enforcement Agency Involved? (Ex: other jurisdiction, etc.)
Additional LE Agency
LEadd Agency
Additional LE Title
LEadd Title (ie - Investigator, Detective, Sergeant, Special Agent, etc.)
Additional LE

LEadd FirstLEadd Last
Additional LE Mobile#
LEadd Mobile#Format: 000-000-0000.
Additional LE Email
LEadd@email.com
Additional LE Supervisor Title
Additional LE Supervisor Title (ie - Investigator, Detective, Sergeant, Special Agent, etc.)
Additional LE Supervisor Name

LEaddSup FirstLEaddSup Last
Additional LE Supervisor Mobile#
LEaddSup Mobile#Format: 000-000-0000.
Additional LE Supervisor Email
AdditionalLE@email.com
# Children being referred for CME

How many children [with SAME PRIMARY CARETAKER(s)] are being referred for CME?
# Children being referred for CME at SAFEchild (If referring >4 children, please complete separate referral(s) for those children)
CHILD 1
Child 1 NAME

Child FIRSTChild LAST
Child 1 Nickname or Preferred Name
Child Nickname or Preferred Name
Child 1 Date of Birth

MonthDayYear
Child 1 Gender Identity

Other
Child 1 Race/Ethnicity

Other
Child 1 Language

Other
Child 1 School or Daycare
Child 1 School or Daycare Name
CHILD 2
Child 2 NAME

Child 2 FIRSTChild 2 LAST
Child 2 Nickname or Preferred Name
Child 2 Nickname or Preferred Name
Child 2 Date of Birth

MonthDayYear
Child 2 Gender Identity

Other
Child 2 Race/Ethnicity

Other
Child 2 Language

Other
Child 2 School or Daycare
School or Daycare Name
CHILD 3
Child 3 NAME

Child 3 FIRSTChild 3 LAST
Child 3 Nickname or Preferred Name
Child 3 Nickname or Preferred Name
Child 3 Date of Birth

MonthDayYear
Child 3 Gender Identity

Other
Child 3 Race/Ethnicity

Other
Child 3 Language

Other
Child 3 School or Daycare
School or Daycare Name
CHILD 4
Child 4 NAME

Child 4 FIRSTChild 4 LAST
Child 4 Nickname or Preferred Name
Child 4 Nickname or Preferred Name
Child 4 Date of Birth

MonthDayYear
Child 4 Gender Identity

Other
Child 4 Race/Ethnicity

Other
Child 4 Language

Other
Child 4 School or Daycare
School or Daycare Name
CHILD 5
Child 5 NAME

Child 4 FIRSTChild 4 LAST
Child 5 Date of Birth

MonthDayYear
Child 5 Gender Identity

Other
Child 5 Race/Ethnicity

Other
Child 5 Language

Other
Child 5 School or Daycare
School or Daycare Name
CHILD 6
Child 6 NAME

Child 4 FIRSTChild 4 LAST
Child 6 Date of Birth

MonthDayYear
Child 6 Gender Identity

Other
Child 6 Race/Ethnicity

Other
Child 6 Language

Other
Child 6 School or Daycare
School or Daycare Name
CURRENT PLACEMENT/HOUSEHOLD

At the time of this CME referral, the CHILD(REN) reside...
CURRENT PLACEMENT/HOUSEHOLD Type

Other
CURRENT PLACEMENT/HOUSEHOLD Address

Name of Caretaker

Street Address

CityState

Zip
Did the child reside at the current placement/household during the time of the reported concerns for maltreatment?
PLACEMENT/HOUSEHOLD at time of concerns for maltreatment

Name of Caretaker

Street Address

CityState

Zip
Were other children residing in the home at the time of the concerns for maltreatment?
Are there concerns for maltreatment for these children? (If yes, please add the additional children to this referral or place a new referral on behalf of those children)?
CAREGIVER 1

PRIMARY CAREGIVER for CHILD
Primary Caregiver NAME

First NameLast Name
Primary Caregiver RELATIONSHIP to CHILD
Primary Caregiver's relationship to Child (ie: Biologic Mother, Adoptive Father, Paternal Aunt...)
Primary Caregiver's Date of Birth

MonthDayYear
Primary Caregiver Mobile #
Primary Caretaker Mobile #Format: 000-000-0000.
Primary Caregiver Email
Caretaker1@email.com
Primary Caregiver Gender

Other
Primary Caregiver Race or Ethnicity

Other
Primary Caregiver Language

Other
Does child have another primary caregiver?
CAREGIVER 2

SECOND PRIMARY CAREGIVER for CHILD
Second Caregiver NAME

First NameLast Name
Second Caregiver RELATIONSHIP to CHILD
Second Caregiver Relationship to Child (ie: Biologic Mother, Adoptive Father, Stepmother, etc.)
Second Caregiver Date of Birth

MonthDayYear
Second Caregiver Mobile #
Second Caretaker Mobile #Format: 000-000-0000.
Second Caregiver Email
Caretaker2@email.com
Second Caregiver Gender

Other
Second Caregiver Race or Ethnicity

Other
Second Caregiver Language

Other
OTHER CHILDREN in PRIMARY RESIDENCE:
Name(s), DOB, Age, Relationship to CHILD
SECOND HOUSEHOLD Address

Street Address

Street Address

CityState

Zip
Child Maltreatment Concerns & History
CHILD MALTREATMENT CONCERNS - (check all that apply)

Other
Date report was received

MonthDayYear
CHILD MALTREATMENT ALLEGATIONS (Please include a detailed account of the allegations, including estimated date(s) of reported maltreatment, timeline of events and investigation so far, summary of interviews completed so far, summary of supplemental information gathered so far, details of scene investigation if completed, details of reported injuries/medical concerns child has as a result of reported maltreatment, and any concerns regarding caregiver(s) or environment.)
Is this child's case/investigation ASSOCIATED WITH or LINKED TO OTHER CASES?

Other
ADDITIONAL CASE(S) associated with this referral
CASE(S) connected - be as specific as possible with names & associations
SAFETY PLAN for CHILD
Safety Plan (legal, formal, or informal)
CHILD &/or FAMILY HISTORY with Child Welfare/DCDEE &/or LE. Has child had CME previously?
History - Prior CME(s) or Interview(s)? Prior Child Welfare/DCDEE &/or LE involvement/investigation?
INTERPRETER SERVICES for CME Appointment
DISABILITY/DELAY Describe any concern for disability or delay for CHILD's or CARETAKER(s) - SPEECH, motor-development, social skills, cognitive, physical, or mental health.
Known cognitive, physical, or mental health impairments for child or caretaker
MEDICAL CARE received by CHILD related to CHILD MALTREATMENT CONCERN(s)/ALLEGATION(s) ex: sexual assault medical forensic examination [SBI Kit])?
MEDICAL PROVIDER or FACILITY NAME
Medical Provider or Facility who cared for CHILD related to referral concerns
MEDICAL CARE DATE(s) of SERVICE ~approximate~
Date of Medical Care related to referral concerns
EMERGENT APPOINTMENT CONSIDERATIONS

- SAFETY: Are there immediate safety concerns for child(ren) or caregiver(s)?

- Continued Contact of Child & Alleged Perpetrator

- AP significant Flight Risk

REFER PATIENT TO EMERGENCY DEPARTMENT IMMEDIATELY FOR THE FOLLOWING:

- Inappropriate sexual contact within the past 72 hours.

- Medical complaints related to concerns for maltreatment (i.e. vaginal bleeding or pain, bruising, altered mental status, etc.)

- All children under 2 years old living within a home with concerns for physical abuse.
EMERGENT CME appointment being requested?
Alleged Perpetrator (AP)

Demographics, VOCA Risk Factors, CSEC/CSAM, Prior History
Is an alleged perpetrator identified?
AP NAME

AP First NameAP Last Name
AP RELATIONSHIP to CHILD
AP Relationship to Child (ie: Biologic Mother, Adoptive Father, Stepmother, Paternal Aunt...)
AP Date of Birth

MonthDayYear
AP LIVES WITH Child currently or prior to investigation?

Other
AP has CUSTODY RIGHTS to Child?

Other
AP Date of LAST KNOWN CONTACT with Child *if ongoing enter today's date*

MonthDayYear
AP Race or Ethnicity

Other
AP History with Child Welfare, DCDEE, &/or Law Enforcement
AP history
UPLOADS & CME Referral Submission

UPLOAD Digital Images (injury/scene), Forms, Medical Records
UPLOAD: DIGITAL IMAGE(s) - label each with provided by, taken by, & date taken

DIGITAL IMAGE(s) upload HIPAA COMPLIANT
Cancelof
UPLOAD: CME CONSENT FORM signed, complete with SIS# or CNDS# by SOCIAL WORKERS ONLY!!!

CME CONSENT FORM upload HIPAA COMPLIANT
Cancelof
UPLOAD: MEDICAL RECORDS or Consent to Release Medical Records to SAFEchild

MEDICAL RECORDS or CONSENT to RELEASE MEDICAL RECORDS upload HIPAA COMPLIANT
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UPLOAD: ADDITIONAL DIGITAL DOCUMENTS

ADDITIONAL DIGITAL DOCUMENTS
Cancelof
Should be Empty:

Referral for Child Medical Evaluation (CME) at SAFEchild Advocacy Center

Child Welfare & DCDEE

Law Enforcement

# Children being referred for CME

CHILD 1

CHILD 2

CHILD 3

CHILD 4

CHILD 5

CHILD 6

CURRENT PLACEMENT/HOUSEHOLD

CAREGIVER 1

CAREGIVER 2

Child Maltreatment Concerns & History

Alleged Perpetrator (AP)

UPLOADS & CME Referral Submission