District No.

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

Name (if known) or description

.......... Applicant

of ..........

........ Respondent

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

WHEREAS APPLICATION was made to this Court on the ... day of ..... 19... by the ...... Health Board under section 18 (1) of the above-mentioned Act for a care 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 board and in the said court district,

AND WHEREAS the said application has not yet been determined by the Court,

NOW, THE COURT on the application of the applicant herein under section 18 (6) of the Act for a supervision order in respect of the said child pending such determination,

*(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 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 applicant health board, pending the determination of the application for the care order, 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 cease to have effect on the determination of the application for the care order.

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

Signed ..........

Judge of the Children Court

* Delete words inapplicable