District No.

In the matter of ........... a child

.......... Applicant

of ........

.......... Respondent

of ............

WHEREAS PROCEEDINGS entitled as above, brought under section ..... of the ...... (Act), 19.. in respect of the above-named child, who resides at ....... in the area of the health board and in the said court district, were before this Court today,

AND WHEREAS it appeared to the Court that it might be appropriate for a care order or a supervision order to be made with respect of the said child and, under section 20 (1) of the Child Care Act, 1991, the Court adjourned the proceedings and directed that health board to undertake an investigation of the child's circumstances,

NOW, THE COURT being satisfied that there are reasonable grounds for believing that—

*(the child has been/is being assaulted/ill-treated/neglected/sexually abused),

(OR)

*(the child's health/development/welfare has been/is being avoidably impaired/neglected),

(OR)

*(the child's health/development/welfare is likely to be avoidably impaired/neglected), and it is desirable that the child be visited periodically by or on behalf of the health board, and

that the welfare of the child so requires,

HEREBY AUTHORISES the ........ Health Board, pending the outcome of the said investigation, to have the said child ....... visited on such periodic occasions as the board may consider necessary in order to satisfy itself as to the welfare of the child and to give to *(her/her parents) *(the person acting in loco parentis) any necessary advice as to the care of the child.

*[AND DIRECTS under section 19 (4) of the Child Care Act, 1991 (as to the care of the child) as follows:—

]

Dated this ... day of ...... 19......

Signed ................

Judge of the Children Court

* Delete words inapplicable