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Document Stating Family Should Have a Say in DCF Placement

 

RE:       , DOB:

 

Dear      :

 

Recognizing the importance of family and its meaning in the lives of children, federal and state law now require expanded opportunities for adult family members to participate in the care and placement of related children who are in the custody of the Department of Children and Families (DCF).  This focus recognizes that, where possible, a child’s best interests are served by remaining in the context of family, culture, and community. The Department of Children and Families is required to exercise due diligence to identify adult relatives of children who come into our care, and to provide the adult relatives with resource information about the programs and services available to relatives.

 

You have been identified as an adult relative of the child(ren) named above and this letter is being sent to you to advise you that your relative is currently in the care of DCF.  I encourage you to contact me as soon as possible in order to discuss your ability and willingness to participate in your relative’s case.  I may be reached at      . I look forward to hearing from you.

 

After talking with me, if you wish to be considered as a placement resource for your relative, your next step will be to complete the Application for Foster Care.  I can provide you with the application when we meet or I can mail or e-mail the application to you.

 

Your relative may be placed with you on an emergency basis while you complete the licensing process, provided that the Department conducts an emergency home assessment and initial background screen which do not identify any potential licensing barriers.  To start this process it is important that you contact me as soon as you receive this letter.

 

The Application for Foster Care requires you to provide information about yourself and other adults and children in your home, including information about criminal court involvement and prior involvement with the Department of Children and Families.  The application also asks for information about your medical history and mental health history, as well as any substance abuse issues.  You will also need to include information about the physical layout of your home and any firearms, weapons and pets in your home.   You will need to provide three references and a financial statement as part of the application process.  Finally, you will need to participate in nine hours of training to become licensed by DCF. While this process may seem complex, it is necessary to comply with state and federal law, and we will be happy to assist you with completing the application.

 

If you become licensed through the Department, you will receive foster care payments, which currently range between approximately $25-$28 per day, depending on the child’s needs, and you may also be eligible for some additional services.  The attached list provides a summary of these services.

 

In addition, after the child has been placed with you as a foster parent for six months, you may be eligible for the subsidized guardianship program.  Once you indicate an interest in the guardianship program, the DCF worker will assess the placement in terms of whether or not this is a viable permanent plan for the child.  Under this program, DCF files a motion in court to end DCF’s involvement as legal guardian of the child and to transfer guardianship to you, the licensed relative.   If you are approved as permanent guardian, the amount of the monthly subsidy will be negotiated with you. The child will be enrolled in health insurance at state expense. You may also be eligible for additional one-time subsidies to cover unusual expenses.

 

Additionally, the Department of Social Services has recently modified its Care 4 Kids rules so that DCF subsidized guardian families are treated the same way as foster care families.  The income of DCF subsidized guardians is no longer counted toward eligibility or payment levels. Therefore, you may be eligible for day care assistance as well.

 

State law also addresses what will happen if you are unable to continue to serve as the child’s guardian.  In the event of your death, severe disability or serious illness, DCF may transfer the guardianship subsidy to a new relative caregiver who meets the foster care licensing requirements and is appointed guardian by a court.

 

Please be aware that if you request to be a placement resource and the Department determines that you do not qualify to hold a license as a foster parent, you may still ask to intervene in the child’s legal proceeding before the Superior Court for Juvenile Matters for the purpose of obtaining temporary custody of your relative. If you file your request within ninety days of the first hearing in the case, the court will grant the motion to intervene, except for good cause shown.  If you wait longer than ninety days, the court has greater discretion to decide whether or not to allow you to intervene, except that your request will be granted (absent good cause) whenever the child’s placement has disrupted or is about to disrupt.   If the court allows you to intervene, the court may request that you release your medical records, including any psychiatric or psychological records, and may require you to submit to a medical or physical examination.  The Department is responsible for paying for any court-ordered examinations.  You may contact the Juvenile Court with jurisdiction over your case at   for information on how to intervene in the case.

 

In addition, you may also ask the court for permission to intervene in the case for the purpose of seeking permanent guardianship of your relative child, regardless of whether DCF agrees.  The court has discretion to grant or deny your motion to intervene, except that the motion will be granted (absent good cause) whenever the child’s most recent placement has disrupted or is about to disrupt.

 

 

In addition, if you become a licensed foster parent for your relative child or if the court grants temporary custody to you, and the Department objects to your request to become the child’s permanent legal guardian or adoptive parent, the Department must prove to the court that transfer of guardianship to you or adoption by you is not in the best interests of the child and that you are not a suitable and worthy person.  If the court determines that DCF has not proven this, you will be awarded legal guardianship or be allowed to adopt the child.

 

 

 

 

This letter provides you with information about the options that are available under current law for you to participate in the care and placement of your relative.  Time is of the essence in responding to this request, as we must make placement decisions that serve the best interests of your relative child.  Placement with family members promotes the best interests of the child and maintains important family connections.  As outlined above, there are numerous services that are available to assist you. Please call me immediately if you have any questions or if you would like more information about the various options available to you.

 

There are also several time sensitive deadlines set forth above.  Failure to adhere to any of these deadlines could result in your relative’s placement in a non-family foster home.  In addition, failure to abide by the court’s deadlines for intervention could preclude you from participating in the court process.

 

I encourage you to contact me so I can assist you with reviewing all these options and providing you with any forms that you may need.   I look forward to hearing from you.

 

 

 

Sincerely,

 

 

 

, Social Worker

 

 

cc:  Assistant Attorney General

 

 

 

 

 

 

 

     

 

 

 

     

     

     

 

RE:       , DOB:       

 

Dear      :

 

Recognizing the importance of family and its meaning in the lives of children, federal and state law now require expanded opportunities for adult family members to participate in the care and placement of related children who are in the custody of the Department of Children and Families (DCF).  This focus recognizes that, where possible, a child’s best interests are served by remaining in the context of family, culture, and community. The Department of Children and Families is required to exercise due diligence to identify adult relatives of children who come into our care, and to provide the adult relatives with resource information about the programs and services available to relatives.

 

You have been identified as an adult relative of the child(ren) named above and this letter is being sent to you to advise you that your relative is currently in the care of DCF.  I encourage you to contact me as soon as possible in order to discuss your ability and willingness to participate in your relative’s case.  I may be reached at      . I look forward to hearing from you.

 

After talking with me, if you wish to be considered as a placement resource for your relative, your next step will be to complete the Application for Foster Care.  I can provide you with the application when we meet or I can mail or e-mail the application to you.

 

Your relative may be placed with you on an emergency basis while you complete the licensing process, provided that the Department conducts an emergency home assessment and initial background screen which do not identify any potential licensing barriers.  To start this process it is important that you contact me as soon as you receive this letter.

 

The Application for Foster Care requires you to provide information about yourself and other adults and children in your home, including information about criminal court involvement and prior involvement with the Department of Children and Families.  The application also asks for information about your medical history and mental health history, as well as any substance abuse issues.  You will also need to include information about the physical layout of your home and any firearms, weapons and pets in your home.   You will need to provide three references and a financial statement as part of the application process.  Finally, you will need to participate in nine hours of training to become licensed by DCF. While this process may seem complex, it is necessary to comply with state and federal law, and we will be happy to assist you with completing the application.

 

If you become licensed through the Department, you will receive foster care payments, which currently range between approximately $25-$28 per day, depending on the child’s needs, and you may also be eligible for some additional services.  The attached list provides a summary of these services.

 

In addition, after the child has been placed with you as a foster parent for six months, you may be eligible for the subsidized guardianship program.  Once you indicate an interest in the guardianship program, the DCF worker will assess the placement in terms of whether or not this is a viable permanent plan for the child.  Under this program, DCF files a motion in court to end DCF’s involvement as legal guardian of the child and to transfer guardianship to you, the licensed relative.   If you are approved as permanent guardian, the amount of the monthly subsidy will be negotiated with you. The child will be enrolled in health insurance at state expense. You may also be eligible for additional one-time subsidies to cover unusual expenses.

 

Additionally, the Department of Social Services has recently modified its Care 4 Kids rules so that DCF subsidized guardian families are treated the same way as foster care families.  The income of DCF subsidized guardians is no longer counted toward eligibility or payment levels. Therefore, you may be eligible for day care assistance as well.

 

State law also addresses what will happen if you are unable to continue to serve as the child’s guardian.  In the event of your death, severe disability or serious illness, DCF may transfer the guardianship subsidy to a new relative caregiver who meets the foster care licensing requirements and is appointed guardian by a court.

 

Please be aware that if you request to be a placement resource and the Department determines that you do not qualify to hold a license as a foster parent, you may still ask to intervene in the child’s legal proceeding before the Superior Court for Juvenile Matters for the purpose of obtaining temporary custody of your relative. If you file your request within ninety days of the first hearing in the case, the court will grant the motion to intervene, except for good cause shown.  If you wait longer than ninety days, the court has greater discretion to decide whether or not to allow you to intervene, except that your request will be granted (absent good cause) whenever the child’s placement has disrupted or is about to disrupt.   If the court allows you to intervene, the court may request that you release your medical records, including any psychiatric or psychological records, and may require you to submit to a medical or physical examination.  The Department is responsible for paying for any court-ordered examinations.  You may contact the Juvenile Court with jurisdiction over your case at   for information on how to intervene in the case.

 

In addition, you may also ask the court for permission to intervene in the case for the purpose of seeking permanent guardianship of your relative child, regardless of whether DCF agrees.  The court has discretion to grant or deny your motion to intervene, except that the motion will be granted (absent good cause) whenever the child’s most recent placement has disrupted or is about to disrupt.

 

 

In addition, if you become a licensed foster parent for your relative child or if the court grants temporary custody to you, and the Department objects to your request to become the child’s permanent legal guardian or adoptive parent, the Department must prove to the court that transfer of guardianship to you or adoption by you is not in the best interests of the child and that you are not a suitable and worthy person.  If the court determines that DCF has not proven this, you will be awarded legal guardianship or be allowed to adopt the child.

 

 

 

 

This letter provides you with information about the options that are available under current law for you to participate in the care and placement of your relative.  Time is of the essence in responding to this request, as we must make placement decisions that serve the best interests of your relative child.  Placement with family members promotes the best interests of the child and maintains important family connections.  As outlined above, there are numerous services that are available to assist you. Please call me immediately if you have any questions or if you would like more information about the various options available to you.

 

There are also several time sensitive deadlines set forth above.  Failure to adhere to any of these deadlines could result in your relative’s placement in a non-family foster home.  In addition, failure to abide by the court’s deadlines for intervention could preclude you from participating in the court process. 

 

I encourage you to contact me so I can assist you with reviewing all these options and providing you with any forms that you may need.   I look forward to hearing from you.  

 

 

 

                                                                   Sincerely,

 

 

 

                                                                        , Social Worker

 

 

cc:  Assistant Attorney General    

 

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CHECKLIST FOR AN ORDER OF TEMPORARY CUSTODY WHEN NEGLECT PETITIONS WERE PREVIOUSLY FILED

DCF-2013                                                                                                                       Page 1 of  2

11/05  (Rev.)                                                State of Connecticut

Department of Children and Families

 

 

 

CHECKLIST FOR AN ORDER OF TEMPORARY CUSTODY WHEN NEGLECT PETITIONS WERE PREVIOUSLY FILED

 

____  Call in to Court

 

____  Motion/Order of Temporary Custody/Order to Appear (JD-JM-58)   

            One (1) notarized original to the court

One (1) copy for the case record

Page 1 = OTC date goes in boxed name HEARING DATE – PRELIMINARY HEARING ON TEM. CUSTODY AND Neglect date goes in box named HEARING DATE – PETITION

 

____  Motion to Amend Neglect (if not yet adjudicated)

 

____  Motion to Open and Modify Disposition if Child is under Protective Supervision

 

____  Summary of Facts Supporting Motion to Amend or Open and Modify

 

____  Notice of Order of Temporary Custody/Order to Appear (JD-JM-58A)

            One (1) original and one

One (1) copy for the case record

OTC date goes in on LINE #2 regarding PRELIMINARY HEARING

 

____    Social Worker Affidavit 

One (1) notarized original

Ten (10) copies to the court, plus one (1) copy for the case record.

____    Supporting statement from other sources, as applicable

One (1) notarized original

Ten (10) copies to the court, plus one (1) copy for the case record.

 

____    Specific Steps (JD-JM-106 or 106S)

            Submit one (1) Specific Steps form for each parent

Originals to the AAG, one (1) copy for case record

 

____    Affidavit for Out of Home Placement (DCF-1999)

One (1) notarized original to the court

One (1) copy of notarized original for the case record

 

 

DCF-2013                                                                                                                                                   Page 2 of 2

11/05 (Rev.)

 

 

____    Instructions to the Marshal

            One (1) form per family should list each individual to be served and their address

Original to the court

Served by date and a Return of Service date goes on line named ON OR BEFORE.  Put the letters ROS in front of the Return of Service date.

Original brought back to the office and immediately submitted to Court/AAG Liaison with the petition packet to be served.

 

____    Notification of Out of Town Placement

If initial placement is out of the town where the child resides, you must notify the court at the time that you file the OTC why placement was not made in the town where the child resides by filing this form.  The notification is only necessary for the initial placement, NOT each time the child is moved.

 

____    Notice to Foster Parents

To be prepared and sent by DCF social worker.  CANNOT be sent until you receive the hearing date.  One (1) original to foster parent, one (1) copy to the AAG, one (1) copy to case record.

 

____    Motion for Order of Notice by Certified Mail (DCF-2011)

To be used if the parents/guardians reside at a known address out-of-state.

One (1) original and one (1) copy to court, one (1) copy in case record.

 

TO BE FILED IF PARENT’S WHEREABOUTS ARE UNKNOWN

 

____    Affidavit Regarding Diligent Search for the Parents’ Identity and/or          

            Location (DCF-2037)

To be used if the parent(s)/guardian(s)’ whereabouts or identity are unknown.  MUST contact known relatives, known employers, Information, and Departments of Correction and Social Services.  Internet search of phone records can be done through paralegal if town is unknown.

One (1) notarized original of each affidavit to the court; one (1) copy in the case record.

(Have the original notarized; then make a copy and place it in the case record.)

 

____    Motion for Order of Notice (DCF-2010)

            To be used if the parent(s)/guardian(s)’ whereabouts are unknown

One (1) original to the court; one (1) copy in the case record.

 

____    Order of Notice (JD-JM-61)

            One (1) original to the court; one copy in the case record.

(For publication purposes only, if the parent(s)/guardian(s)’whereabouts are unknown.)

Neglect date goes on line that begins THE PETITION, WHEREBY THE COURT’S DECISION….and the court location should also be filled in on this line.  OTC date goes on line that begins HEARING ON A ORDER OF TEMPORARY CUSTODY.  To publish on John Doe – state at Notice To = Father of male/female child, born on _____ to Mother’s first name and last initial in Town where child was born.  Use JD-JM 61A.

 

____    Form Letter to Newspaper

            For publication purposes only, if parents/guardians’ whereabouts are unknown.

One (1) original to court, one (1) copy for the case record.

Incoming search terms:

  • ct dcf protective supervision information

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CHECKLIST FOR FILING AN ORDER OF TEMPORARY CUSTODY WITH NEGLECT

DCF-2012                                        State of Connecticut                                       Page 1 of 2

01/07 (Rev.)                          Department of Children and Families

 

 

CHECKLIST FOR FILING AN ORDER OF TEMPORARY CUSTODY WITH NEGLECT

(The number of copies required may vary depending on the court.)

 

____    Calls in to Court

 

____    Petition:  Neglected, Uncared-For, Dependent Child/Youth (JD-JM-98)

One notarized original (front and back) and nine (9) copies (only copy the front) to court, plus one (l) copy in case record (until a signed, dated copy is returned by the court.)

[If an addendum is used as a juris statement, have it signed by the Duly Authorized Agent (Program Supervisor) and clipped to the petition.]

Note: The nine (9) copies are for mother, father, child’s attorney, parents’ attorneys (2), AAG, DCF, CSO, and CIP.  If you know the particulars of your case and there is for example, no known father or father’s attorney, then make seven (7) copies instead of nine (9).

 

____    Motion/Order of Temporary Custody/Order to Appear (JD-JM-58)

            One (1) original and one (1) copy to the court; one (1) copy for the case record.

Note:  Fill out the box at the top of the form.

 

____    Summary of Facts Substantiating Allegations of Neglect

One (1) original and nine (9) copies to court, plus l copy in case record.

 

____    Social Worker Affidavit

One (1) notarized original and nine (9) copies to the court plus one (1) copy for        the case            record.  (Have the original signed by a Notary Public, then make the copies.)

 

____    Supporting statement from other sources, as applicable

One (1) notarized original and nine (9) copies to the court plus one (1) copy for the case      record.

Note:  The statement must be in an affidavit format, which can be accomplished

            by notarizing the reporter’s written DCF-136, “Report of Suspected

            Abuse/Neglect.”

 

____    Custody Affidavit (JD-JM-30)  One (1) notarized original to court, plus one (1) copy to case record.  Have original notarized, then make the copy for the case record.

Note: The affidavit is signed by the Social Worker.

 

____    Motion for Order of Notice (DCF-2010)

            (To be used if the parent(s)/guardian(s)’ whereabouts are unknown)

One (1) original to the court plus one (1) copy in the case record.

 

 

 

DCF-2012                                                                                                                                    Page 2 of 2

11/05 (Rev.)

 

____    Order of Notice (JD-JM-61)

            One (1) original to the court, plus one (1) copy in the case record.

(For publication purposes only, if the parent(s)/guardian(s)’

whereabouts are unknown.) If parent is unknown, use JD-JM-61A.

 

____    Affidavit Regarding Diligent Search for the Parents’ Identity and/or          

            Location (DCF-2037)

            (To be used if the parent(s)/guardian(s)’ whereabouts or identity are unknown)

One (1) notarized original to the court, plus one (1) copy in the case record.

(Have the original notarized; then make a copy and place it in the case record.)

 

____    Motion for Order of Notice by Certified Mail (DCF-2011)

            (To be used if the parent(s)/guardian(s)’ reside at a known address out-of-state)

One (1) original and one (1) copy to the court; one (1) copy in the case record.

 

____    Affidavit for Out of Home Placement (DCF-1999)

            Two (2) notarized originals to the court, plus one (1) copy in the case record.

(Have the originals notarized; then make a copy and place it in the case record.)        After    the Judge signs, be sure to put one original in the case record, because this is mandatory for        federal funding.

____    Social Study

One (1) original and six (6) copies to the court, plus one copy in the case record.

NoteIt is not feasible to have a Social Study completed at the time of an Order of

            Temporary Custody.  The Social Study is required at least three (3) days prior to      the Neglect (Plea) hearing.

 

____    Adjudicatory/Dispositional Orders (JD-JM-65)

            One (1) original and one (1) copy to the court, plus one (1) copy for the case record.            Once signed, it needs to be returned to DCF and placed in the case record.

 

____    Notice to Foster Parents

 

____    Notice to Grandparents

 

____    Notice of Out of Town Placement

 

____    Non-Disclosure Affidavit

 

____    Specific Steps (JD-JM-106, JD-JM-106S)

 

____    Notice of OTC

 

____    Instructions to Marshal

 

____    Letter to Newspaper

 

Incoming search terms:

  • ct dcf order of temporary custody
  • court forms dcf custody case ct
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  • dcf temporary custody form
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  • order for temporary custody ct

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CT DCF-800 Notice of Proposed DSR

DCF-800

DCF-800 State of Connecticut

03/94 (Rev.) Department of Children and Families Page 1 of 2

NOTICE OF PROPOSED DENIAL, SUSPENSION, REDUCTION, OR

DISCONTINUANCE OF DEPARTMENT OF CHILDREN AND FAMILIES BENEFITS

Date: _____/_____/_____

Child’s Name

c/o

Address

Dear __________________________________:

This is to notify you that pursuant to CONN. GEN. STAT. §____________________, the Department of Children and Families is proposing to:

 SUSPEND, effective date: ______/_____/_____

 REDUCE, from ___________ to ______________, effective date: _____/_____/_____

 DISCONTINUE, effective date: _____/_____/_____

Type of Benefit:

Policy, Statute, Reference (if applicable):

 DENY, effective date: _____/_____/_____

Reason:

If you disagree with the Department’s proposed action, you have the right to request a hearing.  * If you are presently receiving benefits and you request a hearing within ten (10) days or by _____/_____/_____, your benefit will continue until the end of the payment period in which a hearing decision is made.  However, if the decision upholds the Department and the benefit is continued beyond the date of eligibility, you may be asked to reimburse the Department.

* If you do not request a hearing within ten (10) days, your benefit will stop or be reduced but you still have until _____/_____/_____ or sixty (60) days to request a hearing.

Complete The Form On The Reverse If You Wish To Ask For a Hearing

Mail To:Department of Children and Families, Administrative Hearings Unit

505 Hudson Street, Hartford, CT  06106

 

 

DCF-800 NOTICE OF PROPOSED DENIAL, SUSPENSION, REDUCTION, OR

03/94 (Rev.) DISCONTINUANCE OF DEPARTMENT BENEFITS Page 2 of 2

To Be Filled Out By Worker

Case Number:

Regional Office

Sub-Office

Unit Supervisor

Telephone Number

Worker

Telephone Number

Date Mailed By Worker

Issue:

I hereby request a hearing because:

(attach an additional sheet of paper, if necessary)

I understand that I may speak for myself or be represented by legal counsel at my expense or by a relative, friend or other person.  I also understand that I have the right to bring witnesses and any documentary evidence to support my position.

I further understand that the hearing may be rescheduled for good reason and that if I am unable to travel because of age or disabling condition, I may request that the hearing be held at my home.

_____________________________________________ ______/______/______

Signed By Person Requesting Hearing        Date

Name of Person Requesting Hearing please print:Name of Child please print

Street Address

CityTelephone Number

Mail this form to:Department of Children and Families, Administrative Hearings Unit, 505 Hudson Street, Hartford, Connecticut 06106

 

Incoming search terms:

  • CT DCF hearing officer

Posted in DCF or CPS, FormsComments (0)

CT DCF-0043 Verification of Requirements for Licensure

DCF-0043 State of Connecticut

DCF-0043 State of Connecticut

05/14/03 (Revised) Department of Children and Families Page 1 of 8

VERIFICATION OF REQUIREMENTS FOR LICENSURE

Parent 1

Name (last, first)

Home Telephone

Work Telephone

Parent 2

Name (last, first)

Home Telephone

Work Telephone

Address

No. and Street

City/Town

State

Zip

Mailing Address

(if different)

No. and Street

City/Town

State

Zip

Application (DCF-354 or DCF-806) dated:

License Type

Primary method of study:

Foster Care

 Group Series

Relative

Town series held in:

Special Study

Begin Date:

End Date:

Independent

Individual – If “individual” give reason(s):

Adoption

Region:   SW      SC      E      NC      NW

LINK #:

Licensed Bed Capacity:

For a Relative, Special Study or Independent license, please list the names of children in placement and their dates of birth.

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

IS the following documentATION contained in the licensing record?

Application (DCF-354 or DCF-806)

Yes

No

Protective Service Check

Yes

No

Local Police Name and Address Search (DCF-2125)

Yes

No

State Police Name Search (DCF-2113)

Yes

No

State Police Fingerprint Card (SP-125c)

Yes

No

FBI Fingerprint Card (FD-258)

Yes

No

Department of Motor Vehicles Check

Yes

No

Marriage/Legal Separation/Divorce (Adoption)

Yes

No

N/A

Physician’s Statement for Foster Care or Adoptive Applicant (DCF-357)

Yes

No

Confidentiality Agreement (DCF-2112)

Yes

No

Disciplinary Agreement (DCF-2111)

Yes

No

Financial Statement (Included on DCF-354 or DCF-806) and verifying documentation

Yes

No

Authorization for a Placement Which Exceeds Population Limitations (DCF-2156)

Yes

No

N/A

 

 

Lead Paint Test Results

Yes

No

N/A

Well Water Test Results (DCF-48)

Yes

No

N/A

Pool Inspection (DCF-49)

Yes

No

N/A

Auxiliary Heating Systems (DCF-446)

Yes

No

N/A

Pet Vaccination Certificate

Yes

No

N/A

References Received (3)

Yes

No

Completed Family Assessment (PRIDE or DCF-805)

Yes

No

Adoption Update

Yes

No

N/A

Family Registration – Adoption (DCF-334)

Yes

No

N/A

                                                                       COMPLIANCE WITH REGULATIONS

  1.  Was the applicant/licensee:

given a copy of department regulations §§17a-145-130 through 17a-145-160?

Yes

No

informed of his/her and the department’s rights and responsibilities indicated in the regulations?

Yes

No

given a copy of the HIPAA provisions?

Yes

No

§17a-145-132

2. Was an assessment completed for each applicant/licensee and all members of the household to determine the ability of the applicant/licensee to comply with the Regulations of Connecticut State Agencies §§17a-145-130 through 17a-145-160?

Yes

No

§17a-145-137

3. Are dwellings and furnishings clean, comfortable and in good repair?

Yes

No

4. Is the home reasonably safe from fire?

Yes

No

5. Are the home and grounds reasonably free from anything that constitutes a hazard to children?

Yes

No

6. Was peeling indoor or outdoor paint accessible to children determined to be non-toxic?

 Yes

No

N/A

7. Is equipment used by the children free from any paint or other covering material which is poisonous?

Yes

No

8. Do all swimming pools comply with local and state regulations?

Yes

No

N/A

9. Are medicines and toxic and flammable materials kept out of the reach of children?

Yes

No

10. Is there sufficient indoor and outdoor space, ventilation, toilet facilities, light and heat to ensure the health and comfort of all members of the household?

Yes

No

11. Do all heating systems comply with state and local building and fire codes?

Yes

No

12. Are there adequate sewage and garbage facilities?

Yes

No

13. Is all power driven machinery or other hazardous equipment properly safeguarded and is/will their use by any foster or adoptive child (be) properly supervised by an adult?

Yes

No

 

 

14. Are emergency evacuation plans established and are/will they (be) practiced at least quarterly with the children?

Yes

No

15. Is a furnace enclosed if it is located on the same floor as a living space?

Yes

No

N/A

16. Are smoke detectors in operating condition and located so as to protect sleep areas, play areas and the basement?

Yes

No

§17a-145-138

17. Is there a working telephone with emergency numbers posted in an easily visible location?

Yes

No

18. Does the applicant/licensee agree to notify the Department within one (1) business day

         of any change in the telephone number or telephone status?

Yes

No

§17a-145-139

19.     Is each bedroom enclosed on all sides, with a window and a door that leads into a

         hallway or other common area?

Yes

No

20. Does each bedroom have at least two (2) approved means of exit capable of providing for escape in the event of fire or disaster?

Yes

No

21. Are bedrooms for children used for sleeping purposes and customary children’s activities only, and not used for general purposes of other members of the family?

Yes

No

22. Do/Will foster and adoptive children under five (5) years of age sleep on the same floor and in close proximity to foster or adoptive parents or a responsible adult?

Yes

No

N/A

23. Is a separate bed provided for each child except that siblings of the same sex may sleep together in a double sized or larger bed with the approval of the commissioner or designee?

Yes

No

24. Does the applicant/licensee agree that:

no child three (3) years of age or older shall be permitted to share a bedroom with another child of the opposite sex or a same sex child of disparate age

no child over one (1) year of age shall share a room with an adult without the permission of the commissioner or designee

no more than four (4) children including the applicant/licensee’s own children shall sleep in the same room without the permission of the commissioner or designee?

Yes

Yes

Yes

No

No

No

N/A

N/A

25. Is children’s clothing kept clean and in good condition in keeping with the standards of the community?

Yes

No

26. Is there safe storage for children’s clothing and personal possessions?

Yes

No

27. Is each child afforded privacy appropriate to his/her growth and development?

Yes

No

§17a-145-140

28. Does all food for human consumption, food storage and preparation, personal cleanliness and general care of the home meet generally accepted health standards?

Yes

No

29. Does the applicant/licensee agree that non-pasteurized milk products will not be provided to any child in care by, or with the approval or knowledge of, the foster or adoptive family?

Yes

No

 

 

30. Is the water supply safe and adequate to meet the needs of the household?

Yes

No

§17a-145-141

31. Does the applicant/licensee or any resident in the home possess a firearm or other type of dangerous weapon?

Yes

No

If yes, does the applicant/licensee ensure that:

firearms and ammunition are locked in separate places inaccessible to all children

whenever practicable, firearms are equipped with a trigger guard lock

other types of dangerous weapons are unstrung or unloaded and stored in locked containers out of the reach of children

keys to the locked storage area of firearms, other types of dangerous weapons, trigger guards, and ammunition are kept in the secure possession of an adult or reasonably secure from children?

Yes

Yes

Yes

Yes

No

No

No

No

§17a-145-142

32. Are all animals kept in a safe and sanitary manner in compliance with all statutes and regulations regarding vaccination and generally accepted veterinary care?

Yes

No

N/A

§17a-145-143

33. Has each person living in the home been determined to be in good health, or are specified members of the family receiving all necessary continuing medical care and are they free of communicable disease?

Yes

No

34. Has the applicant/licensee been determined to be physically and mentally able to provide care to children?

Yes

No

35. Does the applicant/licensee agree to notify the department whenever they or a member of the family contract a communicable disease or if they develop a physical or mental infirmity which interferes with their child-caring ability?

Yes

No

§17a-145-144

36. Are the licensee/applicant and other members of the household of good character, habits and reputation?

Yes

No

§17a-145-145

37. Does the applicant/licensee agree to notify the department, in writing, prior to, or not later than, one (1) business day following, any change in circumstance or member of the household which would alter the statement of fact made in the application for licensure or which would affect the ability of the applicant or licensee to provide ongoing care of the child?

Yes

No

§17a-145-146

38. Does the applicant/licensee agree to notify the department, by telephone, within six (6) hours of any serious injury, serious illness or death of a child, any fire in the home or any unauthorized absence of a child?

Yes

No

§17a-145-147

39. Does the applicant/licensee have an income sufficient to meet the needs of their family?

Yes

No

40. Does the applicant/licensee agree that money received on behalf of the child shall be expended for the care of the child?

Yes

No

 

 

§17a-145-148

41. If all adults in the home are employed or otherwise occupied which requires them to spend a substantial amount of time away from the home, is the care and supervision of the child provided by a competent individual and were the plans for such care approved in advance by the commissioner or designee?

Yes

No

N/A

§17a-145-149

42. Will/Does the applicant/licensee comply with the service plan for the child and work cooperatively with the department in all matters pertaining to the child’s welfare?

Yes

No

43. Will/Does the applicant/licensee accept, cooperate with and support arrangements made for the child to have contact, including visits and correspondence, with the child’s biological family in keeping with the frequency indicated by the service plan; and agree that visits will take place at the foster home or other location if deemed to be in the best interest of the child and foster family?

Yes

No

§17a-145-150

  •  Does the applicant/licensee agree
  •  to possess only one (1) license or approval for adoption or other form of out-of-home care
  •  not to hold dual licensure
  •  not to accept another child for placement on a private basis?

Yes

Yes

Yes

No

No

No

§17a-145-151

45. Is the applicant/licensee physically, intellectually and emotionally capable of providing care, guidance and supervision of the child, including:

ensuring routine medical care, scheduling and transportation

obtaining and following instructions from the child’s medical provider for administering medication or treatment

keeping all medications clearly labeled and out of the reach of children

establishing plans to respond to illness and emergencies, including serious injuries and the ingestion of poison, with appropriate first aid supplies available in the home out of the reach of children

maintaining all documentation as required by the department

providing for the child’s physical needs, including adequate hygiene, nutritional meals and snacks prepared in a safe and sanitary manner, readily available drinking water, a balanced schedule of rest, active play, and indoor and outdoor activity appropriate to the age of the child in care

promoting the social, intellectual, emotional, and physical development of each child by providing activities that meet these needs or any special needs

assuring adequate opportunity for cultural and educational activities in the family and in the community

providing children who do not share the same language as the caretaker with opportunities to practice their native language as they become bi-lingual or multi-lingual

providing adequate opportunity for religious training and participation appropriate to the child’s religious denomination

not requiring any child to participate in religious practices contrary to the child’s beliefs

providing emotional support and an environment that meets the child’s ethnic and cultural needs

assuring the child’s participation in an approved education program, including regular school attendance

Yes

Yes

Yes

Yes

 Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

  •  cooperating with proper authorities regarding the child’s educational needs

  •  guiding the child in the acquisition of daily living skills, including the assigning of daily chores to the child on the basis of the child’s abilities and developmental level

  •  providing infants and toddlers with ample opportunity for freedom of movement each day outside of a crib or playpen

  •  holding infants for all bottle feedings, as well as at other times, for attention and verbal communication?

46.  Does the applicant/licensee agree that they and members of the household, substitute

      care providers and other persons having regular access to children in the home shall

  •  give the child humane and affectionate care

  •  be a positive role model to the child and instruct the child in appropriate behavior

  •  establish limits and assist the child to develop self-control and judgment skills

  •  encourage the children to assume age-appropriate responsibility for their decisions and actions?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

 Yes

No

No

No

No

No

No

No

No

 No

47.  Does the applicant/licensee agree to:

use disciplinary methods appropriate to the child’s age and level of development

not use physically or verbally abusive, neglectful, humiliating, frightening or corporal punishment, including but not limited to spanking, cursing or threats

obtain prior written approval from the commissioner or designee when unusual circumstances require continued or frequent use of physical or mechanical restraints

complete all assessment and training requirements as prescribed by the Department?

Yes

Yes

Yes

Yes

No

No

No

No

§17a-145-152

48.  Is/Has the applicant/licensee or any member of the household:

(a) (Applies to granting an initial license):

1.  been convicted of injury or risk of injury to a minor or other similar offenses against a

    minor

2.  been convicted of impairing the morals of a minor or other similar offenses against a

    minor

3.  been convicted of violent crime against a person or other similar offenses

4.  been convicted of the possession, use, or sale of controlled substances within the

    past five (5) years

5.  been convicted of illegal use of a firearm or other similar offenses

6.  ever had an allegation of child abuse or neglect substantiated

7.  had a minor removed from their care because of child abuse or neglect

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

 

 

(b) (Applies to renewal of a license):

1.  been convicted of injury or risk of injury to a minor or other similar offenses against a

    minor

2.  been convicted of impairing the morals of a minor or other similar offenses against a

    minor

3.  been convicted of violent crime against a person or other similar offenses

4.  been convicted of the possession, use, or sale of controlled substances

5.  been convicted of illegal use of a firearm or other similar offenses

6.  ever had an allegation of child abuse or neglect substantiated

7.  had a minor removed from their care because of child abuse or neglect

(c) (Applies to granting an initial license or renewal of a license):

1.  awaiting trial, or on trial, for charges as described above in (a) 1-5

2.  a criminal record that makes the home unsuitable

3.  a current child abuse or neglect allegation pending?

Yes

Yes

 Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

 No

No

No

No

No

No

No

No

§17a-145-160

49. Does the applicant/licensee agree to accept placements of children in their home in accordance with their license and as specified by regulations?

Yes

No

 

 

Recommendation for Licensure

License Status:

Number of Children:

 Regular

 Waiver

Race:

License Type:

Gender:

Male        Female        Either

 Regular Foster Care         Relative

Special Study         Independent         Adoption

Age Range:

SUBMITTED BY:

FASU Social Worker:

Date:

APPROVED BY:

FASU Social Work Supervisor:

Date:

FASU Program Supervisor:

Date:

REQUEST FOR A WAIVER

(Applies to any type of license)

A waiver may be granted by the commissioner or designee in accordance with the requirements of the Regulations of Connecticut State Agencies §17a-145-159.

Specify the area(s) of substantial compliance or non-compliance and, if required, the alternative plan to achieve compliance:

Approved by FASU Program Director:

Date:

REQUEST FOR A WAIVER

(Applies to RELATIVES ONLY)

In accordance with CONN. GEN. STAT. §17a-114(b) as amended by Public Act 01-70, the commissioner may grant a waiver, for a child placed with a relative, on a case-by-case basis, from a regulatory requirement, except any safety standard, based on the home of the relative and the needs and best interests of such child.

Specify the licensing requirement(s) to be waived and the reason(s):

Approved by FASU Program Director:

Date:

 

 

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Posted in DCF or CPS, FormsComments (0)

CT DCF-2091 Independent Living Case Conference Form

Name:

Name:

LINK Person ID #:

Date of Independent Living Case Conference:

DOB:

Issues regarding youth’s current situation – Please Complete as Applicable

Youth is/has:

  currently registered for a Life Skills program

  currently attending a Life Skills program

  completed a Life Skills program

  preparing for a DCF Independent Living Program

  currently involved in a DCF Independent Living Program (i.e., CHAPS)

  not appropriate for a DCF Independent Living Program

  been referred to an Independent Living Program from another state agency

Mental Retardation (DMR)

Mental Health (DMHAS)

  participating in an Independent Living Program from another agency

Mental Retardation (DMR)

Mental Health (DMHAS)

  a custodial parent

  a non-custodial parent

  preparing for post high school education program

  preparing for post high school vocation program

  participating in Job Corps

  participating in a post high school education program:

  two (2) year program                               post-graduate

  four (4) year program

  participating in a post high school vocational program

  vocational/technical school

  job corps

  Bureau of Rehabilitation Services

  Mentoring program

  Other:

 

 

Areas of Discussion

Discuss the following areas and identify issues relevant to youth, if applicable.  If services are required in any area, the topic must be addressed in the treatment plan service grid.

Education/vocation:

Employment:

Life Skills:

Housing:

Financial:

Health / Mental Health:

Substance Abuse:

 

 

Parenting:

Legal Issues:

Permanency Issues:

Referral to Adult

Services:

Issues of Sexual

Orientation, if

applicable:

Youth’s personal vision for

his/her future-dreams,

aspirations, long-term

goals

Independent Living Passport – Contents

Please indicate if youth needs assistance in obtaining any of the following essential documents.

       Has obtained                  Needs to obtain

   Birth Certificate

   Immigration Documents

   Educational Transcripts

   Driver’s License

    Voter Registration Card

   Other

   Social Security Card

   Health Passport

   Medical Records

For males only:  Has youth registered with the

Selective Service Office?

Yes

                 No

Signatures

Social Worker:

Date:

Social Worker Supervisor:

Date:

Youth:

Date:

Adolescent Services Social Work Supervisor:

Date:

Other DCF staff

Date:

Other DCF staff

Date:

 

 

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CT DCF-2253 Community Housing Employment

DEPARTMENT OF CHILDREN AND FAMILIES

DEPARTMENT OF CHILDREN AND FAMILIES

COMMUNITY HOUSING EMPLOYMENT and ENRICHMENT RESOURCES (CHEER)

CHEER CONTRACT

 (PART I)

This is a binding agreement between

, hereafter named

Participant, and DCF (current social worker)

,

This agreement is only binding during the life of this contract (which cannot exceed three (3) months).  Future Contracts will be created and signed by all parties, during the Participant’s stay in the Community Housing and Employment Resources program.  Failure to comply with this contract will jeopardize the participant’s right to any benefits afforded through CHEER.

This contract is binding beginning

through

(date)

(date)

 This agreement is subject to change if:

(a) any part of it becomes contradictory to future policies or procedures adopted by CHEER;

  1.  negotiated and signed by Participant, and DCF Social Worker and, if appropriate, the

       CHEER support worker.

I. Participant’s responsibilities

A. The Participant will reside at the following address:

Name of CHEER Roommate: _______________________________________________________

*If this address changes, or if anyone other than Participant CHEER approved roommate is residing, frequenting, and/or sleeping in the participant’s apartment,  the Participant agrees to notify his or her DCF Social Worker and CHEER Support Worker within 72 hours.

B. The Participant has completed or is enrolled in

(Name of Program)             (Completion Date)

     Life Skills Program.

C. The Participant will be employed at

The Participant will submit pay stubs to the DCF Social Worker/Support Worker on a monthly basis.

D.  Approved Number of Productive Hours

Life Skills       ___________

Employment       ___________

Therapy       ___________

Other (specify)  ______________________________________________

___________________________________________________________

Total               40 hours

* Any changes in the approved number of productive hours must be agreed upon by the DCF Social    Worker, Social Worker Supervisor and Program Supervisor

E.  The youth will repay the Department for start-up costs monthly. It will be subtracted from the amount allotted for savings or deducted from their subsidy until repaid. When repaid, the budget will be re-negotiated to reflect the new subsidy.

Starting Stipend Amount   _____________________________

    25%     _____________________________

    50%     _____________________________

    75%     _____________________________

      0%     _____________________________

________________________________________________________________________________

Rent Allottment (Full Rent)   _____________________________

    25%     _____________________________

    50%     _____________________________

    75%     _____________________________

      0%     _____________________________

BUDGET – SECTION 1

(TOTAL BUDGET)

The Participant will receive a monthly stipend based, on the following budgeted allotment.

      Rent

$

      Utilities

$

60.

00

      Heat  (if not included in the rent)

$

      Food

$

180.

00

      Telephone

$

35.

00

      Transportation

$

60.

00

      Miscellaneous (household items, HBA’s etc.)

$

60.

00

      Clothing

$

54.

00

SUB TOTAL

$

      *Participant’s Child(ren) Stipend Amount

$

TOTAL MONTHLYCOST

$

     *Child(ren) Stipend Amount must be made as a separate payment.

BUDGET – SECTION 2

(DETERMINING CLIENT CONTRIBUTION)

Earned Net Income

+

Unearned Income

=

Available Monthly Income (AMI)

Available Monthly Income

-

* (40%)

Savings

or

-

(35%)

Spending)

=

(25%)

Participant Contribution

-

(

or

-

)

=

BUDGET – SECTION 3

(DCF SUBSIDY)

Sub Total (Refer to Section I)

$

Participant Contribution (refer to Section II) 25% each quarter

-

$

DCF CHEER Subsidy

=

$

*Participant’s Child(ren) Stipend

+

$

TOTAL MONTHLY COST

=

 *Participant’s Child(ren) Stipend must be submitted as a separate LINK payment.

Please use LINK code 555 CHAP-minor child expense for this payment.

F. This agreement will be reviewed quarterly and the budget will be adjusted each quarter 25% stipend and 25% rent budget.

G. The Participant will meet with the Social Worker at least once a month.
The CHEER Participant will have regular contact with CHEER Support Worker.

H. The Participant will inform the Social Worker within 72 hours of any major changes in his or her situation, including, but not limited to:  quitting or losing a job, leaving an educational/training program, change of address, etc.

*Failure to follow the terms set forth in this agreement may result in termination from the CHEER program.  When the Department of Children and families elects to terminate these   services, a NOTICE OF DISCONTINUATION (CYS 800-801) shall be sent to the Participant.

 

 

II. DCF Social Worker’s Responsibilities

A. The Social Worker will initiate the subsidy payment each month.  The current subsidy

amount is $

per month.

B. The Social Worker will re-negotiate and reduce the budget, contract, and Participant’s

           contribution towards the total cost of care, quarterly.

C. The Social Worker will provide a medical card to the Participant for the duration of his/her  involvement in the CHEER.

D. The Social Worker will meet with the Participant once a month.

E. The Social Worker will collaborate with the Participant on housing and employment.

F. The Social Worker and the Participant, will review the latter’s budget expenditures &

           savings monthly.

G. The Social Worker and the Participant will review the Independent Living and  Transitional Living Case Plans every six months and address issues as needed.

H.        The Social Worker will review this contract every three months (unless a more frequent

           review is required) with the Participant and Support Worker present and the stipend and

           rent allotment will decrease 25% each quarter.

I.         The Social Worker and Social Worker Supervisor will review/approve the Quarterly

          CHEER contract, and monitor 25% decrease in stipends.

J. Additional Information

Please add any additional information, conditions or requirements here:

This agreement will be reviewed on

with the Participant, Case

date

Manager, and DCF Social Worker present.  The Participant will remain eligible for CHEER

as long as the Participant continues to meet DCF policy criteria and remains in good program standing for up to 12 months.

Participant

Date

Social Worker

Date

SW Supervisor

Date

Program Supervisor

Date

Support Worker

Date

 

 

(PART II)

I. Support Worker’s Responsibilities

A. The Participant will meet with the case manager weekly during this contract period,  to review and improve skills in the following areas of concern:

Participant

Date

Support Worker

Date

Social Worker

Date

B. The case manager will submit a Case Manager’s Progress Report form to the Social Worker each month.  A copy will be sent to the Bureau of Adolescent and Transitional Services.

 

 

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Authorization for release of information for DCF CPS Search

09/01/2005 AUTHORIZATION FOR RELEASE OF INFORMATION FOR DCF CPS SEARCH

Authorization for Release of Information for DCF CPS Search

I,

do hereby authorize the Department of Children and Families to research

(Type Applicant Name)

their records for any and all information concerning charges, findings, dispositions, etc., relating to child abuse or neglect in which I/my family may have been named, and to release it to the agency listed below.  I understand that this information will determine my suitability solely for (check one):  Employment     Day Care     Volunteer     Intern     Mentor     Other

By: Agency Name / Address/City / State / Zip Code

Attention:

Agency:

Address:

City:

State:

Zip Code:

I release the Department of Children and Families from any liability for any damages I may incur which may result from the release / use of this information.  I submit my following information to assist the Dept. of Children and Families in their search.

PLEASE  TYPE  OR  PRINT  LEGIBLY  /  LEAVE  NO  BLANK  SPACES

Name:

Date of

Birth:

Address:

Last                                                                                       First                                                         Middle

Social Security #:

Street (No P.O. Boxes)                                                                                                                      Apartment No.

How Long

at Current Address:

 Yrs.     Mos.

City                                                                                                        State                                     Zip Code

Previous Address(es)/List All for the Last Five Years (continue on reverse side of form if necessary)

Check if reverse side used

Street

(No P.O. Boxes)

Apt. #

City/Town

State

Zip Code

Dates

From Month/Yr.

To Month/Yr.

Other Names I have Used – Including Maiden, Previous Marriages(s)

Check if reverse side used

Last

First

Middle

Name of Spouses/Other Adults in the Home – Past and Present

Check if reverse side used

Last

First

Middle

D.O.B.

Month/Day/Year

Social Security #

Signature/Date

(If Still in the Home)

Names of ALL Child(ren) – Biological, Stepchildren Including Adult Children In or Out of the Home

Check if reverse side used

Last

First

Middle

Sex

D.O.B.

Month/Day/Year

Date:

Applicant Signature:

THIS  AUTHORIZATION  WILL  EXPIRE  180  DAYS  AFTER  THE  DATE  OF  THE  SIGNATURE

FORMS  NOT  FILLED  OUT  COMPLETELY  AND  PRINTED  CLEARLY  WILL  BE  RETURNED

****DCF Conducts a Search of the CT Registry ONLY***   The Accuracy of this Search is Limited to the Information Provided by the Applicant to DCF

Mail to:  DCF Hotline Background Searches – 505 Hudson Street – 5th Floor – Hartford, CT 06106

 

 

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Posted in DCF or CPS, FormsComments (0)

CT DCF-xxxx CBLS Referral Form

DCF-xxxx

This is an online fill-in form.   Use the “Tab” key (or mouse pointer) to move to the next field.

DO NOT USE THE RETURN KEY!

NOTE BEFORE COMPLETING THIS REFERRAL FORM:  Youth in PASS, SWETP, TLAP or Level II Group Homes are not eligible for CBLS.  Those programs are required to provide a Life Skills Education Program to the youth residing in their program.  Target population for CBLS is DCF-involved youth, age 15 to 21, residing in an out-of-home placement.  Exclusionary criteria include:  active psychotic behavior, violent/assaultive behavior or active substance abuse.

Youth’s Name:

Date of Referral:

DOB:

Age:

Race:

Ethnicity:

Citizenship status:

Birth Gender:

Current Gender:

Prefers to be called:

Link #:

Address:

City:

State:

Zip:

Phone #:

Cell Phone #:

E-mail:

DCF Area Office:

DCF Worker:

Phone #:

E-mail:

DCF Supervisor:

Phone #:

E-mail:

CBLS Liaison:

Phone #:

E-mail:

LEGAL STATUS

 Committed Abuse/Neglect/uncared for

18 +

 Dually Committed

 Voluntary Services

Type of Placement:

 DCF Foster Home

 Relative Foster Home

 Therapeutic Foster Home

 Residential Facility

 Other:

Placement Contact Name (Foster parent’s or primary case manager)

Provider Phone Number (or Foster parent’s)

Provider Availability (or Foster parent’s):

Expected Living situation with in the next year?:

EDUCATION

School Name:

School Contact Person:

Address:

Contact Phone#

Long term Education Goals:

Current Educational Concerns / Special Needs, if any:

Grade:

Grade Level:

College:

After School Activities, if any:

Will the activities interfere with participation and attendance in class?

College Prep/accelerated

General Studies

GED

Vocational/Technical

Special Ed (reason:  )

 Alternative Learning Program

Long Term Educational Goals:

Current Educational Concerns / Special needs, if any:

Currently Employed?:

 Yes

 No    (Please ensure that the Youth’s work schedule does not conflict with the CBLS Schedule)

If Yes, Where?:

Schedule:

YOUTH INFORMATION

Youth’s Interests:

Youth’s medical conditions / allergies (to food, medications or insects:

DSM IV Diagnosis:

Medications:

Any Special, Relevant Considerations for Educator’s to know?:

Provide a brief assessment of the Youth’s ability and willingness to participate in this program and in a group setting:

Does the youth have a substance abuse history?

 Yes

 No

If yes, is the youth

 Sober

 in Treatment

 Actively using

Provide any information regarding obstacles or issues that the youth is currently dealing with, e.g., living situation, behavioral problems or issues, grief, sexual identity, handicap, illness, etc.

THIS FORM SHOULD BE RETURNED TO THE COMMUNITY BASED LIFE SKILLS

EDUCATOR SERVING THE TOWN / CITY WHERE THE YOUTH IS RESIDING

Please contact your Life Skills Liaison, (one is located in each DCF Area Office), with any questions

 

 

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Mission Statement

The government was formed of checks and balances. Working together allows us to have a louder voice, which demands better responses. We are here for one reason and that is to help with the flow of information and try to help anyone who we can, any way we can.

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