NOTICE: Watch a video of Commissioner Vannessa Dorantes sharing her plan and vision for the agency https://youtu.be/R-lkY9fnAbE

Forms - Numerical Index

DCF-136 - Report of Suspected Child Abuse or Neglect

Jump to form #'s:  1-472   550+  1000+   2000+   2100+   2200+   2300+   3000+   4100 +  Legal Templates (in Word)

NOTE:  You must have ADOBE PDF Reader (at least version 2019.008.20081) to utilize the "form Fill-in" feature

Instructions for individuals who are having difficulty saving documents:
     - select "file"
     - select "save as"
     - select the "drive" and "folder" where you wish to save the document
     - assign a "file name"
     - select "save"

___________________________
Form #'s:  1-549

DCF-Probate-003 Report For the Probate Court For Temporary Custody
DCF-005 – Background Searches
DCF-006 – Interim Licensing Action Requirements for a Foster Care Licensing Change
DCF-007 – Initial Home Visit Assessment Checklist for Core Foster Care or Adoption
DCF-008 – Emergency Home Assessment for Child Specific Placement
DCF-009 – UNDER REVIEW - Foster Care Licensing Placement Waivers Request Form
DCF-011 – Veterinary Statement
DCF-013A – Assessment of Regulatory Compliance
DCF-020 – Physician's Statement for Foster Care Application
DCF-023 – Educational Statement for a Child of a Foster Care or Adoptive Applicant
DCF-Probate-023 – Educational Statement for a Child of a Probate Court Custodian/Guardian Applicant
DCF-030 – Pool Inspection
DCF-043 – Verification of Requirements for Licensure
DCF-047 – Application for Foster Care License
DCF-048 – Request for Inspection of Well Water
DCF-065 – Conditions of Parole Status
DCF-066 – Juvenile Services - Expectations of Placement
DCF-091 – Prospective Foster Family Budget Worksheet
DCF-104 - Internal Discrimination Complaint Intake 
DCF-109 – Functional Family Therapy (FFT) Referral 
DCF-110 - Order for Expedited Placement Decision Pursuant to ICPC Regulation #7
DCF-136 – Report of Suspected Child Abuse/Neglect
DCF-159  – Immediate Removal/96-Hour Hold of Child(ren)
DCF-159S – Immediate Removal/96-Hour Hold of Child(ren) (Español)
DCF-160 – Immediate Removal/96-Hour Hold Placement Notification
DCF-160S - Immediate Removal/96-Hour Hold Placement Notification (Español)
DCF-333 - Wendy's Wonderful Kids Referral
DCF-334 – Adoption Resources Exchange (ARE) Family Registration
DCF-335 – Withdrawal/Placement Notification
DCF-336 – Child's Registration (FORM IS LOCATED IN LINK ONLY)
DCF-337 – Genetic Parent(s) Information (Use When Submitting to Superior Court)
DCF-Probate-337 – Genetic Parent(s) Information
DCF-338 – Medical Information on Genetic Parent (Use When Submitting to Superior Court)
DCF-Probate-338 – Medical Information on Genetic Parent(s)
DCF-354– Application for Foster Care or Adoption
DCF-357 – Physician’s Statement for Foster Care or Adoptive Applicant
DCF-Probate-357 – Physician's Statement for Voluntary Services/Probate Applicant
DCF-383A – Authorization: Therapeutic One-to-One Safety Staffing
DCF-383B – Billing Invoice: Therapeutic One-to-One Safety Staffing
DCF-416 – Certification of Special Needs Status
DCF-418-AG – Annual Guardianship Subsidy Agreement
DCF-418-I  – Initial Adoption Subsidy Agreement
DCF-418-IS – Initial Adoption Subsidy Agreement (Español)
DCF-418-IG – Initial Agreement for a Guardianship Subsidy
DCF-419 – Commissioner's Statement of Support
DCF-421  – Agreement for Placement Before Adoption
DCF-425A – Application to Renew a License for Foster Care or Adoption
DCF-425B – Recommendation for License Renewal
DCF-446 – Inspection of Auxiliary Heating Source
DCF-449 – Permission to Place and Treat Child/Youth in Voluntary Services Program
DCF-460 – Informed Consent For Necessary Or Emergency Health Care
DCF-460A – Permission To Deliver or Obtain Routine Health Care
DCF-460B - Permission for Specialty Consultation and Evaluation
DCF-460MDE – Permission to Conduct a Multidisciplinary Evaluation and Release of Information
DCF-460MDE (ES) - Permission to Conduct a Multidisciplinary Evaluation and Release of Information (Español) 
DCF-460MDE-A – Multidisciplinary Evaluation Child/Youth Permission for Release of Information
DCF-460MDE-A (ES) - Multidisciplinary Evaluation Child/Youth Permission for Release of Information  (Español)
DCF-461 – Medical Screening for Placement
DCF-462 – DCF Hospital Support and Visitation Plan
DCF-465 – Psychotropic Medication Consent Requests
DCF-465A – Discontinuation of a Psychotropic Medication
DCF-465B – Suspected Adverse Drug Reaction Reporting Form
DCF-465R – DCF Response to Medication Request
DCF-469A – Foster Homes Contacted by the Matcher
DCF-470 – Licensed Caregiver Training Plan
DCF-472 – Connecticut Family Assessment
DCF-526 – Request for Voluntary Placement
DCF-552G - TITLE IV-E Guardianship Subsidy Application

 

Form #'s:  550-999

DCF-603 – (Form in LINK ONLY) – Notification to Local Education Agency of a Department Placement
DCF-604 – Notification Regarding Child's Continued Attendance in School of Origin
DCF-632 – Financial Assistance Required for Post Secondary Education
DCF-633 – Statement of Financial Assistance Post Secondary Education –
DCF-634 – Confirmation of Financial Assistance
DCF-635 – Notification to Bookstore
DCF-720 – Verification of Requirements for Approval/Re-Approval for Foster and Prospective Adoptive Families
DCF-736 – Notification to Department of Agriculture of Suspected Animal harm, Neglect or Cruel Treatment
DCF-737 – Notification to State/Local Police of Suspected Child Sexual Abuse, Severe Physical Abuse and/or Neglect
DCF-738 – Agreement for Reimbursement of Non-Recurring Adoption Expenses
DCF-738S – Agreement for Reimbursement of Non-Recurring Adoption Expenses (Español)
DCF-739 – Application for Reimbursement for Non-Recurring Adoption Expenses
DCF-739S – Application for Reimbursement for Non-Recurring Adoption Expenses (Español)
DCF-741HS – Health summary / Health Passport
DCF-742 – Report of Health Care Visit
DCF-742A – Instructions to Caregiver for Health Passport
DCF-742B – Instructions to Health Providers for Health Passport
DCF-745 – Multidisciplinary Evaluation Info Gathering Questionnaire
DCF-746 – Multidisciplinary Evaluation Report
DCF-747 – Multidisciplinary Summary and Recommendations
DCF-761 – Landlord Notification
DCF-777 – Credit Report Letter to Child's Attorney
DCF-778 – Credit Report Letter to State's Attorney
DCF-779 – Notice at Age of Majority
DCF-779VS – Notice at Age of Majority - Voluntary Services Clients
DCF-780 - Youth Rights and Case Plan Notification
DCF-781 - Transition Extension Application For Postsecondary Graduates
DCF-782 - Proof of  Discharge From Foster Care Letter
DCF-785 – Medical Review Board Referral
DCF-786 – Medical Review Board Recommendation: Commissioner’s Decision
DCF-787 – DMHAS Young Adult Services Program Referral
DCF-788 – DMHAS YAS Referral Checklist
DCF-800 – Notice of Proposed Denial, Suspension, Reduction, or Discontinuance of DCF Benefits
DCF-800A – Clients Agreement to Suspend, Reduce or Terminate DCF Benefits
DCF-805 – Assessment for Licensure for a Relative, Special Study, or Independent (Interstate Compact) Home
DCF-823 – Exceptional Circumstances (Replaces the DCF-824, effective February 1, 2019)
DCF-901 – Child and Family Teaming Summary Report
DCF-906 - Report To Superior Court For Juvenile matters Regarding Child's Foster Home Placement

Form #'s:  1000-1999

DCF-1011 – Motion for Determination Regarding Continuation in Care
DCF-1091 – Initial Assessment for Authorization to Provide Respite care
DCF-1091B – Requirements for the Provision of Respite Care to Children with Complex Medical Needs
DCF-1092 – Authorization to Provide Respite Care
DCF-1094 – Assessment for Renewal of Authorization to Provide Respite Care
DCF-1095 – Child Profile for Respite Care
DCF-1101 – Intimate Partner Violence - Family Assessment Intervention Response Referral Form
DCF-1102 – Intimate Partner Violence - Family Assessment Intervention Response Discharge Form
DCF-1248 – Safety Communication System for Deaf and hard of Hearing Parents and Caregivers
DCF-1999 – Affidavit Seeking Out-of-Home Placement of a Child

 

Form #'s:  2000 - 2099

DCF-2005 – Checklist for Filing Neglect Petitions
DCF-2010 – Motion for Order of Notice By Publication
DCF-2011 – Motion for Order of Certified Mail, Restricted Delivery
DCF-2012 – Checklist for Filing an Order of Temporary Custody with Neglect
DCF-2013 – Checklist for Filing Order of Temporary Custody When Neglect Petitions Were Previously Filed
DCF-2014C – Motion to Defer (Criminal)
DCF-2014N – Motion to Defer (Neglect)
DCF-2015 – Motion for Continuance
DCF-2016 – Checklist for Filing Termination of Parental Rights
DCF-2018 – Checklist for Filing Motion to Review Plan for Child for Whom DCF is the Statutory Parent
DCF-2020 – Checklist for filing Revocation of Commitment Petitions
DCF-2029 – Notification to Parent(s) Guardian Change of Visitation Schedule
DCF-2029 S – Notification to Parent(s) Guardian Change of Visitation Schedule (Español) 
DCF-2030 – Notification of a Change in Placement
DCF-2030s – Notification of a Change in Placement (Español)
DCF-2037 – Affidavit Regarding Diligent Search for Parent's Identity and Location
DCF-2039 – Child Assessment
DCF-2043 – Permanency Planning Team Referral Form
DCF-2043G – Referral to Permanency Planning Team for Subsidized Relative Guardianship
DCF-2044 – Child Teaming Pre-Questionnaire
DCF-2045 – Permanency Planning Team Report
DCF-2045G – Permanency Planning Team Report for Subsidized Relative Guardianship
DCF-2048 – Rating Sheet
DCF-2048G – Rating Sheet for Subsidized Relative Guardianship
DCF-2051G – Subsidized Guardianship Approval Checklist 
DCF-2069 – Notification of a Placement Review Team Meeting
DCF-2070 – Determination of a Placement Review Team
DCF-2082 – Notification to Foster Parent of Child's Planned Placement Change
DCF-2084 – Adolescent Case Transfer Conference
DCF-2086 – Determination of Reviewer
DCF-2091 – Independent Living Case Plan
DCF-2092 – Adolescent Transition Plan
DCF-2095 – Application for Re-Entry to Adolescent Services Program
DCF-2097 – Application for Financial Assistance For Post Secondary Education

 

Form #'s:  2100-2199

DCF-2101 – Certification of a Child’s Complex Medical Needs
DCF-2101S – Certification of a Child with Complex Medical Needs for Subsidized Adoptions and Subsidized Guardianships
DCF-2102 – Discharge Plan for a Child with Complex Medical Needs
DCF-2103 – Extraordinary Expenses-Care of a Child with Complex Medical Needs
DCF-2106 – PPSP Accounting Invoice
DCF-2107 – Service Agreement, PPSP
DCF-2109 – Authorization for Release of Information for Foster Care License –
DCF-2111 – Disciplinary Agreement
DCF-2112 – Confidentiality Agreement
DCF-2112S – Confidentiality Agreement (Español) 
DCF-2116 – Network/Security Change Request Form
DCF-2124 – Title IX: Sex Discrimination Grievance Form
DCF 2124A – Title IX Informal Resolution
DCF-2125 – Authorization for Local Police Criminal Records Search
DCF-2126  – Regional Resource Group Consultation Request
DCF-2127 – Caretaker Log of Visits to Providers
DCF-2131(F) – Authorization for Release of Information From DCF
DCF-2131(T) – Authorization for Release of Information To DCF
DCF-2131(F) (Arabic) – Authorization for Release of Information From DCF (Arabic)
DCF-2131(T) (Arabic) – Authorization for Release of Information To DCF (Arabic)
DCF-2131(F) (French) – Authorization for Release of Information From DCF (French)
DCF-2131(T) (French) – Authorization for Release of Information To DCF (French)
DCF-2131S(F) – Authorization for the Release of Information From DCF (Español)
DCF-2131S(T) – Authorization for Release of Information To DCF (Español)
DCF-2131(F) (Vietnamese) – Authorization for Release of Information From DCF (Vietnamese)
DCF-2131(T) (Vietnamese) – Authorization for Release of Information To DCF (Vietnamese)
DCF-2140 – Authorization for Out-of-State Travel for a Foster Child
DCF-2147 – Medical Questionnaire/Request for Information
DCF-Probate-2147 – Medical Questionnaire/Request for Information (Probate)
DCF-2152 - Change of Worker or Parent's Address
DCF-2153 – Authorization for Private Facilities to Exceed DCF Licensed Bed Capacity
DCF-2157 – Authorization Bed held
DCF-2158 – Assessment of Child and Family for Relative Guardianship
DCF-2159 – Application for Guardianship Subsidy
DCF-2163 – Request for Case Management Services (CHAP/CHEER)
DCF-2163A – Request for Case Management Services Non-Per Diem Provider
DCF-2166A – Adolescent Services Service Agreement
DCF-2171 – USD 2 Lesson Plan
DCF-2175 – Voluntary Services Program - Initial Information
DCF-2177 – Voluntary Service Program Application for Services
DCF-2180 – Safety Plan
DCF-2190 – Therapeutic Child Care Gatekeeper Form

 

Form #'s:  2200 - 2999

DCF-2210 – Notification of Investigation Results
DCF-2210-(AR) – Notification of Investigation Results (Arabic)
DCF-2210-(FR) – Notification of Investigation Results (French)
DCF-2210-(FR-CA) – Notification of Investigation Results (French-Canadian)
DCF-2210-(HC) – Notification of Investigation Results (Haitian-Creole)
DCF-2210-(S) – Notification of Investigation Results (Español)
DCF-2210-B – Request for Appeal of Substantiation Finding(s)/Recommendation for Placement on Central Registry
DCF-2210-B(AR) – Request for Appeal of Substantiation Finding(s)/Recommendation for Placement on Central Registry (Arabic)
DCF-2210-B(FR) – Request for Appeal of Substantiation Finding(s)/Recommendation for Placement on Central Registry (French)
DCF-2210-B(FR-CA) – Request for Appeal of Substantiation Finding(s)/Recommendation for Placement on Central Registry (French-Canadian)
DCF-2210-B(HC) – Request for Appeal of Substantiation Finding(s)/Recommendation for Placement on Central Registry (Haitian-Creole)
DCF-2210-B(SP)  – Request for Appeal of Substantiation Finding(s)/Recommendation for Placement on Central Registry (Español)
DCF-2210-C – Notification of Investigation Results (Non-Perpetrator Parent or Guardian)
DCF-2210-C(AR) – Notification of Investigation Results (Non-Perpetrator Parent or Guardian) (Arabic)
DCF-2210-C(FR) – Notification of Investigation Results (Non-Perpetrator Parent or Guardian) (French)
DCF-2210-C(FR-CA) – Notification of Investigation Results (Non-Perpetrator Parent or Guardian) French-Canadian)
DCF-2210-C(HC) – Notification of Investigation Results (Non-Perpetrator Parent or Guardian) (Haitian-Creole)
DCF-2210-C(SP) – Notification of Investigation Results (Non-Perpetrator Parent or Guardian) (Español)
DCF-2212 – Notification of Internal Review Results (CMS)
DCF-2212-Spanish - Notificación del los Resultados de la Revisión Interna
DCF-2213 – Deferral of Review of Investigation Results
DCF-2213-Spanish – Aplazamiento de la Revisión de los Resultados de la Investigación
DCF-2223– Certification of Title IV-E Status
DCF-2226 – Interstate Compact Referral Checklist
DCF-2227 – Social Work Statement of Potential Placement (ICPC)
DCF-2236 – Notice of Privacy Practices
DCF-2236 (Arabic) – Notice of Privacy Practices (Arabic)
DCF-2236 (French) – Notice of Privacy Practices (French)
DCF-2236 S – Notice of Privacy Practices - Spanish
DCF-2236 (Vietnamese) – Notice of Privacy Practices - Vietnamese
DCF-2240 – Motion to Review Permanency Plan/Maintain Commitment/Revoke Commitment/Transfer Guardianship
DCF-2248 – Adoption Placement-Child Disclosure
DCF-2248S – Adoption Placement-Child Disclosure  (Español)
DCF-2251 – Community Housing Assistance Program (CHAP) Contract
DCF-2252 – Community Housing Employment Enrichment Resources (CHEER) Contract
DCF-2257 – Authorization: One-to-one Staff
DCF-2258 – Billing Invoice: One-to-one Staff
DCF-2260 – Authorization for release of photos and videos
DCF-2260S – Authorization for release of photos and videos (Español)
DCF-2270 - Congregate Care Quarterly Nursing Assessment
DCF-2271 - Congregate Care Discharge Summary
DCF-2272 - Monthly Medication Administration Program Supervision and Review
DCF-2273 - Medication Administration Program Internship Verification Form
DCF-2274 - Medication Administration Program Skills Verification
DCF-2275 - Medication Administration Program Procedure Checklist
DCF-2276 - Medication Administration Program Facility Internship Objectives & Criteria
DCF-2277 - Medication Incident Report

 

Form #'s:  2300 - 2308

DCF-2300 - Wilderness School Student Application
DCF-2301 - Referring Agency Background Interview
DCF-2302 - Wilderness School Student Contract
DCF-2303 - Non-Prescription Medication Authorization (OTC)
DCF-2304 - Prescription Medication Authorization (Pediatric)
DCF-2305 - Prescription Medication Authorization (Psychiatric)
DCF-2306 - Wilderness School Medication Checklist
DCF-2307 - Wilderness School Clothing List (5-7-Day Expedition)
DCF-2308 - Wilderness School Clothing List (20-Day Expedition)
DCF-2309 - Wilderness School Enrollment Process Checklist

 

Form #'s:  3000 - 3999

DCF-3001 – Community Based Life Skills Program - Referral Form
DCF-3002 – One on One Mentoring Program - Annual Report
DCF-3004 – Court Notification of OTC Placement
DCF-3005 – Letter to Relatives of Children Taken into DCF Care
DCF-3006 – Letter to Parents Requesting Relative Information
DCF-3007 – Services Available to Relative Caregivers
DCF-3008 – Report of Secure Transport
DCF-3009 – Notification of Court to Out of Town Placement
DCF-3010 – Unique Service Expenditure Application (USE)
DCF-3011G – Family Protective Factors Guide
DCF-3011WS – Family Protective Factors Worksheet
DCF-3012 – Application for Approval: Prevention and Emergency Safety Intervention Training Program
DCF-3013 – Attachment A (Appointment of Health Care Representative)
DCF-3014 – Attachment B (Living Will)
DCF-3015 – Unique Service Expenditure Review (USE)
DCF-3016 – Unique Service Expenditure Waiver Request
DCF-3018 – Notice of Liability – 37-4, 37-4-1
DCF-3019 – Intake-Voluntary Services Initial Request (Only to be utilized by Careline staff)
DCF-3020 – Instructions for Completion of Notice of Liability (DCF-3018) and Financial Assessment of Legally Liable Relative
DCF-3021 – Preferred Elements: Prevention and Emergency Safety Intervention Training Program
DCF-3022 – Required Elements: Prevention and Emergency Safety Intervention Training Program
DCF-3023 – Application for Approval: Prevention & Emergency Safety Intervention Training Program
DCF-3025 – Notification of Family Assessment Response Results
DCF-3027 – Photo ID Replacement Request
DCF-3028 – DCF/DDS Voluntary Services Program Transfer/Closing Summary
DCF-3029  – Notice of Denial of Voluntary Services
DCF-3030 – Notification to Foster Parent of Court Hearing
DCF-3030S – Notification to Foster Parent of Court Hearing (Español)
DCF-3031 – Authorization for Release of Information for DCF CPS Search (This form is for: Employment, Day Care, Volunteers, Interns and Mentors)
DCF-3032 – Athorization for Release of Information for DCF CPS Search
DCF-3033 – Foster Care and Adoption Background Search Release (This form is for prospective foster and adoptive parents only)
DCF-3034 – Field Visit Reporting Form
DCF-3035 – Considered Removal Child and Family Team Meeting
DCF-3036 – Considered Removal CFTM Summary Report
DCF-3037 – Considered Removal Sign In Sheet For Meeting Participants
DCF-3038 – Considered Removal Participants and Concerted Efforts
DCF-3040 – Child and Family Permanency Teaming Sign-In Sheet for Meeting Participants
DCF-3050 – Secondary Employment Request
DCF-3060 – Adult Adoptee Request for Information
DCF-3061 – Contact Preference and Reunion Registry Form for Genetic Parents
DCF-3062 – Adult Adoptee Request for Adoption Search
DCF-3107 – Acceptable Use of LexisNexis System
DCF-3125 – Grant Development Approval Protocol (FOR DCF STAFF ONLY)

 

Form #'s:  4100+

DCF-4100 – Extended Day Treatment Referral form
DCF-4101 – Supervision Session Agenda
DCF-4200 – Data Use Agreement
DCF-4928 – Foster Family Profile

Legal Templates

Adoption Template – Format for the Adoption Social Study


Additional DCF Forms

FMLA-HR1 – FMLA Employee Request
FMLA Guidelines – Understanding Family and Medical leave
DCF-MA1 – Medical Assistance Form
M2T – Notification of Change Form
P33A – FMLA - Employee Medical Certificate
P33B – FMLA - Caregiver Medical Certificate
W1Y – HUSKY Application
W-1HUSHUSKY APPLICATION and RENEWAL Form
USD-187 – USD 2 Comprehensive Health Education Exclusion Request Form

Additional State Agency forms:

DAS Human Resources
Department of Developmental Services (DDS)
Interstate Compact
Judicial Department
Superior Court for Juvenile Matters
Workers Compensation

Non-DCF Forms

30-C – Workers Compensation of Connecticut Form for Notice of Claim for Compensation
CO-1317 – CT HEP Physical Notification Form
DCF-MA1 – Medical Assistance Form
FD-258 – Finger Print Card
PER WC-207 – Report of Occupational Injury or Disease to an Employee
PER WC-207-1 – Supervisor's Accident Investigation Report
W-1621 – Guarantee of Reimbursements
WCC-1A – Filing Status and Exemption Form

Interstate Compact Forms

ICPC 101 – Sending State Priority Home Study Request – 47-3-7
ICPC 100A – Interstate Compact Placement Request (and instructions) – 47-3-7
ICPC 100B – Interstate Compact Report on Child's Placement Status (and instructions) – 47-3-7

Juvenile Court Forms

JD-CL-140 – Firearm Safety Warrants
JD-FM-142 – Restraining Orders: How to Apply from Relief from Abuse|
JD-JM-30 – Custody Affidavit
JD-JM-31 – Order, Termination of Parental Rights and Appointment of Statutory Parent/Guardian
JD-JM-31A – Order, Cotermination of Parental Rights and Appointment of Statutory Parent/Guardian
JD-JM-40 – Petition for Termination of Parental Rights
JD-JM-58 – Motion/Order of Temporary Custody/Order to Appear
JD-JM-58A – Notice/Order of Temporary Custody/Order to Appear
JD-JM-60 – Affidavit/Consent to Termination of Parental Rights
JD-JM-61 – Order of Notice
JD-JM-61A – Notice to Unidentified Person
JD-JM-65 – Adjudicatory/Dispositional Orders
JD-JM-76 – Revocation of Commitment/Guardianship custody/Temporary custody/Subsequent Order of Custody/Temporary Custody Guardianship/Protective Supervision
JD-JM-98 – Petition: Neglected, Uncared-For, Dependent Child/Youth
JD-JM-106 – Specific Steps
JD-JM-106S – Pasos Specíficos (Español)
JD-JM-120 – Non School Complaint, Family With Service Needs
JD-JM-120A – Family With Service Needs - Parental Notice
JD-JM-129 – Permanency Plan Order and Review
JD-JM-149 – Order of Temporary Custody