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
Child Welfare AgencyNC Division of Child Development and Early Education (DCDEE)Law Enforcement Agency
Child Welfare & DCDEE
YesNoUnknown at this time
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
YesNo
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
YesNoUnknown at this time
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
YesNo
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?
123456
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
FemaleMaleNon-Binary, Gender Neutral, or Gender InclusiveOther
WhiteBlack/African AmericanHispanic/LatinoAsianAmerican Indian/Alaska NativeNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
EnglishSpanish (interpreter required)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
FemaleMaleNon-Binary, Gender Neutral, or Gender InclusiveOther
WhiteBlack/African AmericanHispanic/LatinoAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
EnglishSpanish (interpreter required)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
FemaleMaleNon-Binary, Gender Neutral, or Gender InclusiveOther
WhiteBlack/African AmericanHispanic/LatinoAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
EnglishSpanish (interpreter required)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
FemaleMaleNon-Binary, Gender Neutral, or Gender InclusiveOther
WhiteBlack/African AmericanHispanic/LatinoAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
EnglishSpanish (interpreter required)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
FemaleMaleNon-Binary, Gender Neutral, or Gender InclusiveOther
WhiteBlack/African AmericanHispanic/LatinoAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
EnglishSpanish (interpreter required)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
FemaleMaleNon-Binary, Gender Neutral, or Gender InclusiveOther
WhiteBlack/African AmericanHispanic/LatinoAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
EnglishSpanish (interpreter required)Other
Child 6 School or Daycare
School or Daycare Name
CURRENT PLACEMENT/HOUSEHOLD

At the time of this CME referral, the CHILD(REN) reside...
Parent/Legal Guardian (home)Parent/Guardian with Temporary Safety Provider (TSP) at homeTSP (outside of home)Foster CareOther
CURRENT PLACEMENT/HOUSEHOLD Address *

Name of Caretaker

Street Address

CityState

Zip
YesNo
PLACEMENT/HOUSEHOLD at time of concerns for maltreatment*

Name of Caretaker

Street Address

CityState

Zip
YesNo
YesNo
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
FemaleMaleOther
WhiteBlack/African AmericanHispanic/LatinoAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
EnglishSpanish (interpreter required)Other
YesNo
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
FemaleMaleOther
WhiteBlack/African AmericanHispanic/LatinoAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
EnglishSpanish (interpreter required)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
NeglectSexual AbusePhysical AbuseMedical Child Abuse ("Munchausen by proxy")Emotional/Psychological AbuseExposure to Domestic ViolenceDependencyTraffickingOther
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.)*
YesNoOther
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?
NONECARETAKER onlyCHILD onlyCHILD & CARETAKER (PLEASE request 2 separate interpreters!)
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
YESNOUNKNOWN
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.
YESNoUnsure
Alleged Perpetrator (AP)

Demographics, VOCA Risk Factors, CSEC/CSAM, Prior History
YesNo, perpetrator is currently unknown
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
YESNOOther
YESNOOther
AP Date of LAST KNOWN CONTACT with Child *if ongoing enter today's date*

MonthDayYear
WhiteBlack/African AmericanHispanic/LatinoAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderMulti-RacialUnknownOther
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
Cancelof
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