CME Referral Form - WPForm - SAFEchild Raleigh NC

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LE/CPS Referral

CME Referral Form

Thank you for your Child Medical Evaluation (CME) referral. Please note that SAFEchild accepts CME referrals from law enforcement and the Department of Social Services (DSS) only. We will follow up with you within 2 business days. If you have any questions or concerns, please call 919-231-5515 or email adavis@safechildnc.org or jfarmerkeating@safechildnc.org.

Referral requested & completed by: *

Social worker/law enforcement officer name

Email: *

Referral Source(s)

DSS involvement? *

Yes
No
Unknown

DSS county:

DSS social worker:

DSS address:

Address Line 1

Address Line 2

City

State

DSS office phone:

DSS cell phone:

DSS email:

DSS fax:

DSS supervisor name:

DSS supervisor phoner:

DSS supervisor email:

Law enforcement involvement? *

Yes
No
Unknown

Law enforcement agency:

Law enforcement officer:

Law enforcement address:

Address Line 1

Address Line 2

City

State

Law enforcement office phone:

Law enforcement cell phone:

Law enforcement email:

Law enforcement fax:

Child Information

Child's full name:

First name, middle name(s), last name

Child's birth date:

Child's age:

Child's gender

Male
Female
Other

Describe "other"

Child's race/ethnicity:

Child's address:

Address Line 1

Address Line 2

City

State

Child's county of residence:

Child's phone:

Child's alternate phone:

CAREGIVER INFORMATION

CAREGIVERS

Mother
Father
Other

Select all that apply

Mother Information

Mother's name:

Relationship to child:

Biological
Adoptive
Step

Mother's birth date:

Mother's age:

Mother's race/ethnicity:

Mother's address:

Address Line 1

Address Line 2

City

State

Mother's county of residence:

Mother's phone:

Mother's alternate phone:

Mother's email:

Father Information

Father's name:

Relationship to child:

Biological
Adoptive
Step

Father's birth date:

Father's age:

Father's race/ethnicity:

Father's address:

Address Line 1

Address Line 2

City

State

Father's county of residence:

Father's phone:

Father's alternate phone:

Father's email:

Other Caregiver Information

Caregiver's name:

Caregiver's relationship to child:

Caregiver's birth date:

Caregiver's age:

Caregiver's race/ethnicity:

Caregiver's address:

Address Line 1

Address Line 2

City

State

Caregiver's county of residence:

Caregiver's phone:

Caregiver's alternate phone:

Caregiver's email:

Additional caregiver?

Yes
No

Additional caregiver's name:

Additional caregiver's relationship to child

Additional caregiver's birth date:

Additional caregiver's age:

Additional caregiver's race/ethnicity:

Additional caregiver's address:

Address Line 1

Address Line 2

City

State

Additional caregiver's county of residence:

Additional caregiver's phone:

Additional caregiver's alternate phone:

Additional caregiver's email:

Household Information

Household #1

Please list each member of the household including: name, age/DOB, relationship to patient
John Doe, 45, 01/01/1975, Father
Jane Doe, 40, 01/01/1980, Mother
Jack Doe, 18, 01/01/2002, Brother
etc.

Second household?

Yes
No

Household #2

Please list each member of the household including Name, Age/DOB, Relationship to Patient
John Doe, 45, 01/01/1975, Father
Jane Doe, 40, 01/01/1980, Mother
Jack Doe, 18, 01/01/2002, Brother
etc.

Referral Concerns

This child has been referred for medical diagnosis related to the following concerns (select all that apply):

Sexual abuse/assault/victimization

Yes
No
Unknown

Report date:

Physical abuse/assault

Yes
No
Unknown

Report date:

Emotional abuse

Yes
No
Unknown

Report date:

Neglect

Yes
No
Unknown

Report date:

Domestic violence exposure

Yes
No
Unknown

Report date:

Dependency

Yes
No
Unknown

Report date:

Child trafficking

Yes
No
Unknown

Report date:

Other concerns?

Yes
No
Unknown

Report date:

Brief description of each concern:

Include disclosure details; type of abuse; frequency; last abusive encounter; neglect contributing to abuse

Disclosure Information

A. Has the child disclosed to a professional?

Yes
No
Unknown

Describe

Include who, when and description of disclosure

B. Has the child disclosed to a non-professional?

Yes
No
Unknown

Describe:

Include who, when and description of disclosure

C. Alleged offender(s) information

Available
Unknown

Name:

Relationship to child:

Birth date:

Age:

Race/ethnicity:

Last known contact date:

Additional alleged offender?

Yes
No

Name:

Relationship to child:

Birth date:

Age:

Race/ethnicity:

Last known contact date:

D. Has patient seen a medical provider related to this concern prior to this evaluation?

Yes
No
Unknown

Describe:

Include date, location, name and contact information:
Investigators: Please obtain consent for release of medical information and obtain pertinent medical records prior to evaluation.

Sexual assault evidence collection kit obtained?

Yes
No
Unknown

Summary of evaluation findings:

Please provide medical records prior to CME.

E. Has this child/family had prior DSS/LE involvement?

Yes
No
Unknown

Describe:

F. Is an interpreter needed for the CME?

Yes
No

Who is the interpreter needed for?

A caregiver
The child

Investigators will be responsible for arranging an interpreter.

G. Has this child been referred for a CFE (for DSS only)?

Yes
No

H. Does the child have any known cognitive/physical/mental health impairments?

Yes
No
Unknown

Describe:

Single Line Text

Comment

SAFEchild
919.743.6140
864 West Morgan Street
Raleigh, NC 27603

SAFEchild Advocacy Center
919.231.5515 (phone)
919.231.5516 (fax)

2815 Kidd Road
Raleigh, NC 27610

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