Forms - Numerical Index

DCF-136 - Report of Suspected Child Abuse or Neglect
DCF-2131 - Authorization for Release of Information (To and From, in various languages)

Jump to form #'s:  1-549   550+  1000+   2000+   2100+   2200+   2300+   3000+   4100 +  Legal Templates (in WordAdditional Forms  Non-DCF Forms

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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 - (WORD) / Permanency Resource Exchange (PRE) 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-415 - Checklist for Adoption Subsidy Approval
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-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 (with Instructions)
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-472 (WORD) Connecticut Family Assessment
DCF-526 – Request for Voluntary Placement

 

Form #'s:  550-999

DCF-552G - TITLE IV-E Guardianship Subsidy Application
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 - Application for Financial Assistance 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 (WORD) – Report of Health Care Visit
DCF-742A – Instructions to Caregiver for Health Passport
DCF-742B – Instructions to Health Providers for Health Passport
DCF-745 (WORD) – Multidisciplinary Evaluation Info Gathering Questionnaire
DCF-746 – Multidisciplinary Evaluation Report
DCF-747 – (WORD) 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
DCF-785 – Medical Review Board Referral
DCF-786 (pdf) - Medical Review Board Recommendation: Commissioner’s Decision
DCF-786 (WORD)– 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-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-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-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-2115 - Mobile Devices (Laptop / Tablet / Cellular Device) Receipt
DCF-2116 – Network/Security Change Request Form
DCF-2118 - Confidentiality Agreement
DCF-2123 - IT Consultants, Volunteer, Mentor or Intern Application & Criminal Justice Information
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) (Español) – Authorization for Release of Information From DCF (Español)
DCF-2131S(T) (Español) – 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-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-2180 Arabic – Safety Plan
DCF-2180 Espanol – Safety Plan
DCF-2180 French – Safety Plan
DCF-2180 Haitian - Safety Plan
DCF-2180 Vietnamese – 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-2226 – Interstate Compact Referral Checklist
DCF-2227 – Social Work Statement of Potential Placement (ICPC)
DCF-2228 - Parent Home Assessment (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/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
DCF-2350 - Request for Inmate Participation in DCF Conference Call
DCF-2351 - Request to Schedule a Visit With an Incarcerated Parent

 

Form #'s:  3000 - 3999

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-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
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 Forms

DCF-MA1– Revenue Enhancement Division - Medical Assistance Form
FMLA-HR1 – FMLA Employee Request
FMLA Guidelines – Understanding Family and Medical leave
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

 

Non-DCF Forms

30-C – Workers Compensation of Connecticut Form for Notice of Claim for Compensation
CO-17XP - Employee Payroll Reimbursements
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

Other State Agencies

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

 

Interstate Compact on the Placement of Children (ICPC) Forms

DCF-101– (ICPC- 101) Sending State Priority Home Study Request (Under Review)
DCF-100A – (ICPC-100A) Request  (Under Review)
DCF-100B – (ICPC-100B)  Report on Child's Placement Status  (Under Review)
DCF-2227 – ICPC Social Work Statement of Potential Placement
DCF-2228 – ICPC Parent Home Assessment

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