.............. Applicant

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

................ Respondent

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

UPON APPLICATION made to this Court to-day by the above-named applicant under section 19 (1) of the above-mentioned Act for a supervision order with respect to the above-named child who *is `appears to be aged .... years, having been born *(so far as has been ascertained) on the ... day of ..... 19.... and who resides at ........ in the area of the applicant health board and in the said court district,

THE COURT being satisfied that notice of the application was duly served, having heard the evidence tendered herein,

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 desirably 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 applicant health board 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 *(his/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 Act (as to the care of the child) as follows:—

]

This order shall remain in force—

*(for the period of twelve months from the date hereof,)

*(from the ... day of ..... 19.... until the ... day of ..... 19...)

unless sooner discharged and, in any event, shall cease to have effect when the person in respect of whom it is made ceases to be a child.

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

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

Judge of the Children Court

* Delete words inapplicable