Forensic Pediatrics Consultants

Please note:

1. The referral is to obtain expert review/consultation on an open CPS case and does not constitute medical care or treatment. This service is limited to assisting public agencies and attorneys in understanding elements of potential abuse.

2. Children should receive initiation of medical care of any potential injuries or issues prior to referral.

3. This service is not available for sexual abuse examinations.

4. This service is not for urgent input on cases nor clinical care. Response time is typically within 72 hours unless you receive a pop-up regarding vacation time. If you do not receive a response within those intervals, please speak to your supervisor.

Today's Date

Caseworker/Law Enforcement Professional Name

Contact Number

Email Address

Patient First Name

Patient Last Name

Patient Date of Birth

Category of Intake (Choose One) Physical Abuse - Child 0-2 Years of AgePhysical Abuse - Child Over 2 Years of AgeNeglect - Child 0-2 Age (including Failure to Thrive)Neglect - Child 0ver 2 Years of Age (including Failure to Thrive)Child FatalityOther

Has Child Seen A Medical Professional Since The Report Was Received?

YES

NO

Is Child Currently Inpatient At A Hospital?

YES

NO

If Child Is Inpatient, Please List What Hospital?

Please provide brief summary of how concern for abuse arose:

If you are human, leave this field blank.