Alphabetical Forms Index

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(Form Name / Form Number / Policy Number)


Adjudicatory/Dispositional Orders, JD-JM-65, 46-3-33
Adolescent Discharge Plan, DCF-2092, 42-7
Adoption Information Checklist for Foster Parent Adoption, DCF-2041, 48-12-4
Adoption Plan Summary, DCF-336 (this form is located in LINK only), 41-40-3.1, 48-7-3, 48-14-6.5
Adoption Readiness Case Consultation, DCF-2040, 48-12-4
Adoption Registration for Medical Information, DCF-2061, 41-40-7
Adoption Report, DCF-420, 48-18-6
Adoption Resources Exchange (ARE) Family Registration, DCF-33441-40-3.4
Adoption Search Data Sheet, DCF-2058, 41-40-7
Adoption Subsidy Agreement, Annual Agreement, DCF-418-A, 41-40-10.4, 48-18-12.2
Adoption Subsidy Agreement, Initial Agreement, DCF-418-I, 41-40-10.348-18-6
Adoptive Home Fact Sheet, DCF-2049, 48-14-6.5
Affidavit Regarding Diligent Search for Parent's Identity and Location, DCF-2037, 46-3-18, 46-3-33, 48-10-1
Affidavit/Consent to Termination of Parental Rights, JD-JM-60, 46-3-21.9, 46-3-33
Affidavit Seeking Out-of-Home Placement of a Child, DCF-1999, 46-3-13, 46-3-33
Affirmative Action Initial Complaint Form, DCF-2124
Agreement for Placement Before Adoption, DCF-421, 48-15-9
Agreement for Reimbursement of Non-Recurring Adoption Expenses, DCF-738, 48-18-6
Annual Agreement for a Relative Guardianship Subsidy, DCF-418-AG, 41-50-11
Application for an Adoption Subsidy After Finalization, DCF-2052, 41-40-10.3
Application for Compact Services, ICJ-1A-VI, 47-4-4
Application for Consideration to the Institutional Review Board, IRB Application Process, 26-8-1
Application for Foster Care License, DCF-047, 41-1
Application for Foster Care or Adoption, DCF-354, 41-1
Application for Post-Adoption Services, DCF-2059, 48-20
Application for Reimbursement for Non-Recurring Adoption Expenses, DCF-739, 48-18-6
Application for a Relative Guardianship Subsidy, DCF-2159, 41-50-4
Application to Renew a License for Foster Care or Adoption, DCF-425A, 41-1
Assessment of Child and Family for Relative Guardianship, DCF-2158, 41-50-3
Assessment for Licensure for a Relative, Special Study, or Independent (Interstate Compact) Home,  DCF-80541-1
Assessment for Renewal of Authorization to Provide Respite Care, DCF-109441-1
Assessment for the Provision of Respite Care to Children with Complex Medical Needs, DCF-1091B, 41-1
Attending Physicians Worker's Compensation Report of Treatment7-15
Authorization for Local Police Criminal Records Search, DCF-2125, 41-1
Authorization for Out-of-State Travel for a Foster Child, DCF-2140, 36-55-12
Authorization for a Placement Which Exceeds Population Limitations, DCF-2156, 41-1
Authorization for Private Facilities to Exceed DCF Licensed Bed Capacity, DCF-2153, 20-8-8
Authorization to Provide Respite Care, DCF-1092, 41-1
Authorization for Release of Information, DCF-2131(F), DCF-2131(T),  31-8-5
Authorization for Release of Information (Spanish), DCF-2131(F)S, DCF-2131(T)S, 31-8-5


Background Searches, DCF-005,  41-1
Books, Supplementary Materials and Equipment Review, DCF-2170, 27-3-20.1


Case Transfer Conference, DCF-2084, 42-1
Certification of a Child's Complex Medical Needs, DCF-2101, 41-7-2
Certification of a Child's Complex Medical Needs (Review for Adoption Subsidy), DCF-2101R, 41-40-10.4
Certification of Special Needs Status, DCF-416, 41-40-10.3, 48-18-6
Change of Worker or Parent’s Address, DCF-2152, 46-3-33
Checklist for Diligent Search, DCF-2245, 46-3-18, 46-3-33
Checklist for Filing Coterminous Petitions-Order of Temporary Custody and Neglect, DCF-2149, 46-3-21.5, 46-3-33
Checklist for Filing for Termination of Parental Rights in Probate Court, DCF-2036, 48-8-2
Checklist for Filing Motion to Review Plan for Child for Whom DCF is the Statutory Parent, DCF-2018, 46-3-25, 46-3-33
Checklist for Filing a Motion to Review Permanency Plan/FWSN, DCF-2246, 46-3-22, 46-3-33
Checklist for Filing a Motion to Review Permanency Plan/Maintain Commitment/Revoke Commitment/Transfer of Guardianship, DCF-2247, 46-3-22, 46-3-33
Checklist for Filing Neglect Petitions, DCF-2005, 46-3-10, 46-3-33
Checklist for Filing an Order of Temporary Custody with Neglect, DCF-2012, 46-3-21.1
Checklist for Filing Order of Temporary Custody When Neglect Petitions Have Been Previously Filed, DCF-2013, 46-3-19, 46-3-33
Checklist for Filing Termination of Parental Rights, DCF-2016, 46-3-21.1, 46-3-33
Checklist for Recruitment Plan, Checklist for Recruitment Plan, DCF-2038, 48-10-2
Child and Adolescent Respite Services Referral Protocol, DCF-2148, 39-21
Child Assessment, DCF-2039, 48-12-2, 48-14-6.5
Child Profile for Respite Care, DCF-1095, 41-1
Child Teaming Pre-Questionnaire, DCF-2044, 48-14-6.5
Child's Registration, DCF-336 (this form is located in LINK only), 41-40-3.1, 48-7-3, 48-14-6.5
Classroom Observation of Academic and Behavioral Performance, DCF-2104, 27-3-19
Clients Agreement to Suspend, Reduce or Terminate DCF Benefits, DCF-800A, 22-4-3, 41-40-10.4, 41-50-12
Closing Checklist, DCF-2220, 36-110-1.1
Closing Information, DCF-2068, 41-40-7
Commissioner's Statement of Support, DCF-419, 48-18-6
Commissioner's Statement of Support After Adoption Finalization, DCF-419A, 41-40-10.3
Conditions of Parole Status, DCF-065, 22-9-3
Confidentiality Agreement, DCF-2112DCF-2112S,  41-1
Confirmation of Financial Assistance, DCF-634, 42-1
Congregate Care Discharge Summary
DCF-2271, 26-1
Congregate Care Quarterly Nursing Assessment, DCF-2270, 26-1
Connecticut Family Assessment, DCF-472, 41-16-12
Consent Form, DCF-2065, 41-40-8
Court Notification of OTC Placement, DCF-3004
Critical Incident Summary/Update Form, DCF-823, 33-1


Data Use Agreement for ORE, DCF-4200
DCF Hospital Support and Visitation Plan, DCF-462, 34-10-7.1
Deferral of Review of investigation Results, DCF-2213, 34-12-8
Determination of a Placement Review Team, DCF-2070, 45-6-2
Determination of Reviewer, DCF-2086, 45-6-2
Discharge Plan for a Child with Complex Medical Needs, DCF-2102, 41-7-6
Disciplinary Agreement, DCF-2111, 41-1


Educational Statement for a Child of a Foster Care or Adoptive Applicant, DCF-023, 41-1
Educational Statement for a Child of a Probate Court Custodian / Guardian Applicant, DCF-Probate-023, 46-4-3
Eligibility Form, DCF-374, 16-3-2
Extraordinary Expenses for the Care of a Child with Complex Medical Needs, DCF-2103, 41-1
Emergency Home Assessment for Child Specific Placement DCF-008, 41-1


Face Sheet for Subsidized Guardianship Record, DCF-2051G, 41-50-10
Family Assessment - For Use With Foster and Adoptive Homes, DCF-472
Family Registration, DCF-334, 41-40-3.4
Financial Assistance Required for Post High School Education, DCF-632, 42-4
Foster or Adoptive Parent Homestudy Packet, DCF-2120, 41-1
Foster Care Licensing Placement Waivers Request Form, DCF-009, 41-1
Foster Family Profile, DCF-4928, 41-1
Foster Homes Contacted by the Matcher, DCF-469A, 41-1


Genetic Parent(s) Information, DCF-337, 41-40-7, 48-7-2, 48-14-6.5
Genetic Parent(s) Information (Use When Submitting to Probate Court), DCF-Probate-337, 48-15-9
Grant Development Approval Protocol (FOR DCF STAFF ONLY) , DCF-3125, 13-5


Health History, DCF-469, 36-50-2
Health Summary, DCF-741HS, 26-1
Health Passport Instruction Sheet for Caregivers, DCF-741A, 26-1
Health Passport Instruction Sheet for Providers, DCF-741B, 26-1
HIV Authorization for Confidential Testing, DCF-2138, Chapter 44
HIV Delegation of Authority for Testing, DCF-2135, Chapter 44


Immediate Removal/96-Hour Hold of Child(ren), DCF-159, 34-10-4.1
Immediate Removal/96-Hour Hold of Child(ren) (Spanish), DCF-159S, 34-10-4.1
Immediate Removal/96-Hour Hold Placement Notification, DCF-160, 34-10-4.1
Immediate Removal/96-Hour Hold Placement Notification (Spanish),  DCF-160S, 34-10-4.1
Independent Living Case Plan, DCF-2091, 42-1
Individual Case Establishment, DCF-378, 48-18-6
Information Consent For Foster Care or Adoption, DCF-2109, 41-1
Informed Consent for Emergency or Necessary Health Care, DCF-460, 26-1
Interim Licensing Action Requirements for a Foster Care Licensing Change, DCF-006, 41-1
Initial Agreement for a Relative Guardianship Subsidy, DCF-418-IG, 41-50-8
Initial Assessment for Authorization to Provide Respite Care, DCF-1091
Initial Assessment Report Form, DCF-2105, 27-3-19
Inspection of Auxiliary Heating Source, DCF-446, 41-1
Interstate Compact Notice of Medicaid Eligibility/Case Activation, ICAMA 6.01, 47-6-1
Interstate Compact Placement Request (and instructions), ICPC 100A, 47-3-7
Interstate Compact Progress Report, DCF-2225, 47-3-7
Interstate Compact Receiving State's Priority Home Study, ICPC-102, 47-3-7
Interstate Compact Referral Checklist, DCF-2226, 47-3-7
Interstate Compact Report of change in Child/Family Status, ICAMA 6.03, 47-6-1
Interstate Compact Report on Child's Placement Status (and instructions), ICPC 100B, 47-3-7
Interstate Compact Sending State Priority Home Study Request, ICPC-101, 47-3-7


Juvenile Services - Expectations of Placement, DCF-066, 22-9-3


Landlord Notification, DCF-761, 41-1
Lesson Plan (USD 2), DCF-2171, 27-3-20.2
Letter of Withdrawal or Confirmation of Request for Administrative Hearing, DCF-800B, 22-2
Licensed Caregiver Training Plan, DCF-470


Medical Alert, DCF-741, 36-50-2
Medical Information on Genetic Parent(s), DCF-338, 36-85-1, 41-40-7, 48-7-2, 48-14-6.5
Medical Information on Genetic Parent(s) (Use When Submitting to Probate Court), DCF-Probate-338, 48-15-9
Medical Permission and Informed Consent for Treatment of a Child who is a Ward of the Commissioner of DCF, DCF-460, 26-1
Medical Request for Information, DCF-2147, 34-11
Medical Review Board Referral, DCF-785, 26-1
Medical Review Board Recommendation: Commissioner’s Decision, DCF-786, 26-1
Medication Administration Program Internship Verification Form, DCF-227326-1
Monthly Medication Administration Program Supervision and Review, DCF-2272,  26-1

Motion/Order of Temporary Custody/Order to Appear, JD-JM-58, 46-3-19, 46-3-33
Motion for Order of Certified Mail, Restricted Delivery, DCF-2011, 46-3-17, 46-3-33
Motion for Order of Notice, DCF-2010, 46-3-17, 46-3-33
Motion to Review Permanency Plan/Maintain Commitment/Revoke Commitment/Transfer of Guardianship, DCF-2240, 46-3-22, 46-3-33
Multidisciplinary Evaluation Info Gathering Questionnaire, DCF-745, 26-1
Multidisciplinary Evaluation Report, DCF-746, 26-1
Multidisciplinary Summary and Recommendations, DCF-747, 26-1


Notice at Age of Majority, DCF-779, 42-1
Notification - Discontinuation of Psychotropic Medication, DCF-465A, 26-1
Notice of Liability to Applicant or Recipient of Care or Support or Legally Liable Relative, W-997, 37-9
Notice of Temporary Custody/Order to Appear, JD-JM-58a, 46-3-1946-3-33
Notice of Privacy Practices, DCF-2236, 44-7-4
Notice of Proposed Denial, Suspension, Reduction, or Discontinuance of DCF Benefits, DCF-800, 22-4-3, 41-40-10.4, 41-50-12
Notice to Unidentified Person, JD-JM-61a, 46-3-33
Notification of Investigation Results, DCF-2210
Notification of Investigation Review Results, DCF-2212 (CMS), DCF-2212-A and DCF-212-B
Notification to Department of Agriculture of Suspected Animal Harm, Neglect or Cruel Treatment, DCF-736
Notification of a Placement Review Team Meeting, DCF-2069, 45-6-2
Notification to Foster Parent of Child's Planned Placement Change, DCF-2082, 36-55-15
Notification to Local Education Agency of a Department Placement, DCF-603 (this form is located in LINK only),
Notification of a Change in Placement, DCF-2030 and DCF-2030S, 36-50-5.3, 36-75-1
Notification to Parent(s) Guardian Change of Visitation Schedule, DCF-2029 and DCF-2029S, 36-75-1
Notification to State/Local Police of Suspected Child Sexual Abuse, Severe Physical Abuse and/or Neglect, DCF-737, 33-1


Ombudsman’s Office Contact Sheet, DCF-2139, 2-4-1
Order, Co-Termination of Parental Rights and Appointment of Statutory Parent/Guardian, JD-JM-31a, 46-3-21.5, 46-3-33
Orders (Adjudicatory/Dispositional), JD-JM-65, 46-3-33
Order of Notice, JD-JM-61, 46-3-17, 46-3-33
Order of Temporary Custody / Motion / Order to Appear, JD-JM-58, 46-3-1946-3-33
Order, Termination of Parental Rights and Appointment of Statutory Parent/Guardianship, JD-JM-31, 46-3-33


Parole or Probation Investigation Request, ICJ-IV, 47-4-4
Pasos Específicos, JD-JM-106s, 46-3-19, 46-3-33
Permanency Placement Services Program Accounting Invoice, DCF-2106, 48-22-2
Permanency Plan Order and Review, JD-JM-129, 46-3-33
Permanency Plan Order and Review/Delinquency/Family With Service Needs, JD-JM-129, 46-3-31, 46-3-33
Permanency Planning Team, Confidentiality Statement for Non-Department Participants, DCF-2050, 48-14-6.5
Permanency Planning Team Log, DCF-2078, 48-14-6.5
Permanency Planning Team Members, DCF-2042, 48-14-6.5
Permanency Planning Team Referral Form, DCF-2043, 48-14-6.5
Permanency Planning Team Report, DCF-2045, 48-14-6.5
Permanency Planning Team Report for Subsidized Relative Guardianship, DCF-2045G, 41-50-3
Permission to conduct a Multidisciplianry Evaluation and Release of Information, DCF-460 MDE, 26-1
Permission to Deliver or Obtain Routine Health Care, DCF-460A, 26-1
Permission to Participate in USD II Educational Field Trips and Program Activities, DCF-2167, 27-3-12
Permission to Place and Treat Child/Youth in Parental Custody, DCF-449, 44-4-2
Petition:  Family With Service Needs, JD-JM-118, 46-3-31, 46-3-33
Petition for Requisition to Return a Runaway Juvenile, ICJ-A, 47-4-4
Petition for Termination of Parental Rights, JD-JM-40, 46-3-21.1, 46-3-33
Petition: Neglected, Uncared-For, Dependent Child/Youth, JD-JM-98, 46-3-10, 46-3-33
Petition/Motion for Initial or Dispositional Hearing on Continuance of Care or Placement of Child/Youth (Court of Probate), CM-48, 37-9
Petition: Youth in Crisis, JD-JM-144, 46-3-32, 46-3-33
Physician's Statement for Day Care or Authorized Respite Care, DCF-722, 36-55-25.10
Physician's State for Foster Care Application, DCF-020, 41-1
Physician’s Statement for Foster Care or Adoptive Applicant, DCF-357, 41-50-3
Placement Plan For a Child With complex Medical Needs, DCF-2102, 41-7-2, 41-7-5
Procedures for Out-of-State Providers of Medical and Related Services to Obtain, CT ICPC, 47-3-6
Prospective Parent Questionnaire, DCF-2120A, 41-1
Psychotropic Medication Consent Request and Instruction Sheet, DCF-465, 26-1
Psychotropic Medication Response Form, DCF-465R, 26-1


Quarterly Voluntary Placement Report, DCF-2080, 36-50-5.6


Rating Sheet, DCF-2048, 48-14-6.5
Rating Sheet for Subsidized Relative guardianship, DCF-2048G, 41-50-3
Recommendation for License Renewal, DCF-425B, 41-1
Record of Adoption, VS-51, 48-19-2
Referral to Permanency Planning Team for Subsidized Relative Guardianship, DCF-2043G, 41-50-3
Regional Resource Group Consultation Request, DCF-2126, 38-2
Renewal of Assessment for Authorization to Provide Respite Care, DCF-1094, 41-1
Report of Absences of Employees from Academy for Workforce Knowledge and Development, DCF-2033, 11-2
Report of Health Care Visit, DCF-742, 26-1
Report of Non-Use of Adoptive Home, DCF-431, 41-40-4.1, 48-14-6.1
Report of Occupational Injury or Disease to an Employee, PER WC-207
Report of Sending State Upon Parolee or Probationer Being Sent to the Receiving State, ICJ-V, 47-4-4
Report To Superior Court For Juvenile matters Regarding Child's Foster Home Placement, DCF-906, 46-3-4
Report of Suspected Child Abuse/Neglect, DCF-136, 33-1
Report to DSS of Abuse or Neglect Involving an Unlicensed Day Care Provider, DCF-2221, 36-106
Request for Additional Case Management Service hours for CHAP Clients, DCF-2163, 42-5
Request for Case Management Services Non-Per Diem Provider, DCF-2163-A, 42-5
Request for Inspection of Well Water, DCF-048, 41-1
Request for Surrogate Parent, DCF-2132, 45-10
Request for Voluntary Placement, DCF-526, 36-50-5.2
Requisition for Escapee / Absconder , Requisition for Juvenile Charged with Being Delinquent, ICJ-II, 47-4-4
Requisition for Runaway Juvenile, Child Removed from Jurisdiction of Court, ICJ-I, 47-4-4
Resource Family Support Plan, DCF-470, 41-1
Respite Care for Licensed Families, DCF-2143, 41-1
Respite Care Placement Requests, DCF-763, 41-1
Revocation of Order of Commitment/Guardianship Custody/ Temporary Custody and Subsequent Order of Custody/Temporary Custody Guardianship/Protective Supervision, JD-JM-76, 46-3-24, 46-3-33


Service Agreement, PPSP, DCF-2107, 48-22-2
Social Information for Probate Court Proceedings, Attachment A, Attachment B, Attachment C, 48-21-5
Specific Recruitment Inquiries, DCF-2063, 41-40-5.1
Specific Steps, JD-JM-106, 46-3-19, 46-3-33
Spending Plan for Flexible Funding for Client Services, DCF-2231, 36-102
Statement of Financial Assistance Post High School Education, DCF-633, 42-1
Status Report for Permanency Planning Team, DCF-2046, 48-14-6.5
Subsidized Adoption Face Sheet, DCF-2051, 48-18-6
Suspected Adverse Drug Reaction Reporting Form, DCF-465B, 26-1


Team Presenters Evaluation Form, DCF-2047, 48-14-6.5
Title IV-E Adoption Subsidy Application, DCF-552, 48-18-6
Title IV-E XIX Application, DCF-550, 41-40-10.5, 37-9, 41-50-7, 48-18-6
Title IV-E/Title XIX Redetermination Form, Adoption Assistance, DCF-552A, 48-18-12.2
Title IX: Sex Discrimination Grievance Form, DCF-2124, 27-3-27
Title VI and Section 504 Grievance Form, DCF-2161, 27-3-28
Transitional Living Case Plan, DCF-2092, 42-7
Transmittal of Adoption Packet, DCF-2053, 48-19-2


Unified School District 2 Jurisdiction Certification, DCF-415, 45-3
Use/Disclosure Complaint, DCF-2238, 44-7-10


Verification of Requirements for Licensure, DCF-0043
Verification of Requirements for Approval/Re-Approval for Foster & Prospective Adoptive Families, DCF-720
Visitation Log, DCF-822, 36-50-2
Voluntary Services Program Application for Services, DCF-2177, 37-9
Voluntary Services Program - Initial Information, DCF-2175, 37-9


Waiver of Requirements for Licensure of Foster/Adoptive Families Pending FBI Clearance, DCF-2233, 41-1
Wednesday’s Child Recruitment Log, DCF-2054, 41-40-5.2
Withdrawal of Application (Voluntary Services), DCF-2179, 37-9
Withdrawal/Placement Notification (Adoption), DCF-335, 41-40-3.1, 48-10-2
Worker Change/Assignment Form, DCF-382, 48-18-6
Workers Compensation of Connecticut Form for Notice of Claim for Compensation, 30-C, 7-6