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Connecticut Birth to Three

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Referrals

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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 Information

2Child Info

3Reason for Referral

Your Name*
Best Phone Number*
Alternate Phone Number 1
Alternate Phone Number 2
FAX Number
Your Agency Address*
Street Address Address Line 2 City State ZIP Code
Email
Are you the caseworker assigned to this child?
- Yes
- No
DCF Caseworker’s name

DCF Caseworker’s name
DCF Caseworker’s email
DCF Caseworker’s phone
DCF Caseworker’s phone
DCF Caseworker’s address
Street Address Address Line 2 City 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 Birth
Does child reside with:*
Adult Name*
Child Address*
Street Address Address Line 2 City State ZIP Code
Adult Home Number
Adult Cell Number
Adult 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 Notes
Child's health plan name
Insurance type
- Private/Commercial
- Medicaid
If you want to review your information, click on the previous button.
Captcha
Check the box above to continue

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