Homepage > Referrals > Forms > DCF Referral Form DCF Referral Form If you have questions, call 1-800-505-7000 to talk with the Child Development Infoline. DCF Referral Form 1Your Information2Child Info3Reason for Referral Your Name* Best Phone Number*Alternate Phone Number 1Alternate Phone Number 2FAX NumberYour Agency Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Are you the caseworker assigned to this child? Yes No DCF Caseworker’s name DCF Caseworker’s nameDCF Caseworker’s email DCF Caseworker’s phoneDCF Caseworker’s phoneDCF Caseworker’s address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Name* Child's Gender* Male Female Date of Birth* Month Day Year Full Term at Birth Yes No Unknown If no, number of weeks born early Hospital of BirthOut of State HospitalHome BirthUnknownAlternative Birthing CenterCT Childbirth & Women CenterBridgeport HospitalBristol HospitalCharlotte Hungerford HospitalDanbury HospitalDay Kimball HospitalGreenwich HospitalGriffin HospitalGroton Naval HospitalHartford HospitalHospital of Central CTJohnson Memorial HospitalLawrence & Memorial HospitalManchester Memorial HospitalMiddlesex HospitalMidstate Medical CenterMilford HospitalMt. Sinai HospitalNew Milford HospitalNorwalk HospitalRockville General HospitalSharon HospitalSt. Francis HospitalSt. Joseph's HospitalSt. Mary's HospitalSt. Raphael Campus - YaleNHHSt. Vincent's Medical CenterStamford HospitalUConn Medical Center- CCMC at Dempsey HospitalUS Coast Guard ClinicWaterbury HospitalWilliam Backus HospitalWindham HospitalYale New Haven HospitalDoes child reside with:*Biological ParentGuardianFoster ParentRelativeSafe HomeAdult Name* Child Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Adult Home NumberAdult Cell NumberAdult best number to use.* Home Cell Primary language spoken in home* English Spanish Other language spoken in home English Spanish Guardianship* DCF Parent Nexus Custody status OTC Committed TPR Reason for Referral (check all that apply)* motor social-emotional/behavioral adaptive cognitive hearing vision Communication Other Other Reasons for Referral Was a developmental screening completed within last 3 months? Yes No Unknown Results OK Not OK Screening Tool Used ASQ PEDS Was an autism screening completed within last 3 months? Yes No Unknown Results OK Not OK Screening Tool Used M-Chat Had Audiological Exam within last 12 months Yes No Unknown If expressive language seems delayed, the child should be screened or evaluated to rule out any underlying hearing loss.Was hearing loss identified Yes No Unnown Does the child have any medical conditions that could lead to a delay in development? Yes No Unnown Medical conditions expected to lead to developmental delay ICD code(s) if known Helpful NotesChild's health plan name Insurance type Private/Commercial Medicaid If you want to review your information, click on the previous button.CaptchaCheck the box above to continue Δ