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 ahubbard@safechildnc.org or mwilfong@safechildnc.org.

Social worker/law enforcement officer name

Referral Source(s)

Child Information

First name, middle name(s), last name

CAREGIVER INFORMATION

Select all that apply

Mother Information

Father Information

Other Caregiver Information

Household Information

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):

Disclosure Information