Name of Child Date of Birth
Name of Child Date of Birth
Name of Child Date of Birth
I hereby authorize to perform:
☐ A Child Medical Evaluations (CME), including diagnostic studies and photographs, on the above-named child.
☐ A Child/Family Evaluation (CFE), including diagnostic studies, on the above-named child.
Furthermore, I authorize the above-named examiner to release the entirety of the medical record to (All items must
be checked):
☐ A county department of social services (DSS) providing protective services to the above-named child
☐ NC Child Medical Evaluation Program (CMEP)
☐ NC Division of Social Services
☐ I understand that, as the parent/legal guardian, I will not have access to Child Medical Evaluation or Child &
Family Evaluation reports.
☐ I understand that limited information can be shared with the parent/legal guardian and medical and/or mental
health professionals providing care to the child post-evaluation. This may include:
• Mental health symptoms
• Physical exam findings
• Laboratory studies
☐ I acknowledge that this evaluation is used to make determinations of child maltreatment and is a component of
a NC child protective services assessment.
This referral is made by authority of (check one):
☐ Parent
☐ Legal Guardian
☐ DSS Director - When acting as temporary guardian of a child found abandoned or without a natural guardian
(G.S. § 35A-1220) or when having been vested with parental rights by the adoption or termination of
parental rights laws (G.S. §§ 48-3-705 and 7B-1112).
☐ Judge’s Order - In accordance with G.S. § 7B-505.1, when a court order authorizes this evaluation.
_________________________________________________________Date:_
Signature of parent/guardian
Please complete form on page 2
