cme-referral-test - SAFEchild Raleigh NC

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Report Child Abuse
LE/CPS Referral

CME Referral Form

CME REFERRAL FORM - Step 1 of 5

Referral Information

Referral Requested & Completed By: *

Social Worker/Law Enforcement Officer Name

Referral Source(s)

DSS Involvement *

Yes
No
Unknown

DSS County:

DSS Social Worker:

DSS Address

Address Line 1

Address Line 2

City

State

DSS Phone:

DSS Cell Phone:

DSS Email:

DSS Fax:

Law Enforcement Involvement *

Yes
No
Unknown

Law Enforcement Agency:

Law Enforcement Contact:

Law Enforcement Address

Address Line 1

Address Line 2

City

State

Law Enforcement Phone:

Law Enforcement Cell Phone:

Law Enforcement Email:

Law Enforcement Fax:

Child Information

Child's Full Name:

Firstname Middlename(s) Lastname

Child's Date of Birth:

Child's Age:

Child's Ethnicity:

Child's Address:

Address Line 1

Address Line 2

City

State

Child's County:

Child's Phone:

Child's Alternate Number:

CAREGIVER INFORMATION

CAREGIVERS

Mother
Father
Other

Select all that apply

Mother Information

Mother's Name:

Mother's Date of Birth:

Mother's Age:

Mother's Ethnicity:

Mother's Address:

Address Line 1

Address Line 2

City

State

Mother's County:

Mother's Phone:

Mother's Alternate Number:

Mother's Email:

Father Information

Father's Name:

Father's Date of Birth:

Father's Age:

Father's Ethnicity:

Father's Address:

Address Line 1

Address Line 2

City

State

Father's County:

Father's Phone:

Father's Alternate Number:

Father's Email:

Other Caregiver Information

Caregiver's Name:

Caregiver's Relationship to Child

Caregiver's Date of Birth:

Caregiver's Age:

Caregiver's Ethnicity:

Caregiver's Address:

Address Line 1

Address Line 2

City

State

Caregiver's County:

Caregiver's Phone:

Caregiver's Alternate Number:

Caregiver's Email:

Additional Caregiver?

Yes
No

Additional Caregiver's Name:

Additional Caregiver's Relationship to Child

Additional Caregiver's Date of Birth:

Additional Caregiver's Age:

Additional Caregiver's Ethnicity:

Additional Caregiver's Address:

Address Line 1

Address Line 2

City

State

Additional Caregiver's County:

Additional Caregiver's Phone:

Additional Caregiver's Alternate Number:

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

Including 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

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

Yes
No
Unknown

Describe

Include Who, When and Description

C. Alleged Offender(s) Information

Available
Unknown

Name

Relationship to Child

Date of Birth:

Age:

Ethnicity

Last Known Contact Date

Additional Alleged Offender?

Yes
No

Name

Relationship to Child

Date of Birth:

Age:

Ethnicity

Last Known Contact Date

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

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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