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Connecticut Birth to Three

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Referrals

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DCF Referral Form

DCF Referral Form

Referrals to Birth to Three are made for children 0 to 34.5 months who you or someone else has a concern about their development. The concern can be from the parent, foster parent, DCF, or anyone else. Concerns can be suspected and does not have to be validated. Only children with noted concerns or diagnosed conditions receive an evaluation.

If there is no concern, contact Help Me Grow at 1-800-505-7000 for resources.

DCF Referral Form

1Your Information

2Child Info

3Reason for Referral

Your Name*
please enter first and last 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
Your email*
Are you the caseworker assigned to this child?
- Yes
- No
Caseworker Name
DCF Caseworker’s email
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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