Form DCF-109 "Functional Family Therapy (Fft) Referral Form" - Connecticut

What Is Form DCF-109?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-109 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-109 "Functional Family Therapy (Fft) Referral Form" - Connecticut

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Connecticut Department of Children and Families
FUNCTIONAL FAMILY THERAPY (FFT) REFERRAL FORM
DCF-109
3/17 (Rev.)
Page 1 of 1
REFERRAL SOURCE:
DATE RECEIVED:
Name:
Agency:
Phone:
Demographics
Child’s
Child’s
Middle:
Gender:
Last Name:
First Name:
Child’s
Child’s
Child’s DOB:
Phone:
Please Select One
Please Select One
Race:
Ethnicity:
Child’s Current DCF Status:
Select One
Child’s Primary Insurance:
ID#:
Child’s Secondary Insurance:
ID#:
Please be advised that HUSKY is the only insurance that pays in full for FFT. Co-pays will be required for
Annual household Income:
privately insured families; however, NO family will be refused services due to financial reasons. Include a
$
signed release and any assessments that might be relevant to treatment, when submitting this form.
Name of Parent/Caretaker:
City/Town:
State:
Zip:
Address:
Parent/Caregiver’s Race:
Parent/Caretaker’s Ethnicity:
Please Select One
Please Select One
Primary Phone:
Work Phone:
Cell Phone:
Primary Language of the Parent/Caregiver:
Child:
Select One
Secondary Language of the Parent/Caregiver:
Child:
Select One
Parent/Caregiver’s Relationship to Child:
Parent
Foster Parent
Guardian
Relative
Other:
Have the caregivers been informed concerning family involvement (no individual sessions, meeting at least weekly for at least nine weeks)?
Yes
No
Persons Living in the home with the Child
Name
Gender
DOB
Relationship to Child
Select One
Select One
Select One
Select One
Select One
Select One
Child’s Mental Health / Medical Issues:
Current DSM-IV Diagnosis
Date:
By Whom:
AXIS I:
AXIS II
AXIS III:
AXIS IV:
AXIS V: Current GAF:
Highest in past 6 months:
Current And Past Behavioral Health Treatment Providers / Agencies (DCF, Probation, Mental Health, Etc.)
Name of Provider / Agency:
Types of Services:
Dates of Services:
Phone:
Connecticut Department of Children and Families
FUNCTIONAL FAMILY THERAPY (FFT) REFERRAL FORM
DCF-109
3/17 (Rev.)
Page 1 of 1
REFERRAL SOURCE:
DATE RECEIVED:
Name:
Agency:
Phone:
Demographics
Child’s
Child’s
Middle:
Gender:
Last Name:
First Name:
Child’s
Child’s
Child’s DOB:
Phone:
Please Select One
Please Select One
Race:
Ethnicity:
Child’s Current DCF Status:
Select One
Child’s Primary Insurance:
ID#:
Child’s Secondary Insurance:
ID#:
Please be advised that HUSKY is the only insurance that pays in full for FFT. Co-pays will be required for
Annual household Income:
privately insured families; however, NO family will be refused services due to financial reasons. Include a
$
signed release and any assessments that might be relevant to treatment, when submitting this form.
Name of Parent/Caretaker:
City/Town:
State:
Zip:
Address:
Parent/Caregiver’s Race:
Parent/Caretaker’s Ethnicity:
Please Select One
Please Select One
Primary Phone:
Work Phone:
Cell Phone:
Primary Language of the Parent/Caregiver:
Child:
Select One
Secondary Language of the Parent/Caregiver:
Child:
Select One
Parent/Caregiver’s Relationship to Child:
Parent
Foster Parent
Guardian
Relative
Other:
Have the caregivers been informed concerning family involvement (no individual sessions, meeting at least weekly for at least nine weeks)?
Yes
No
Persons Living in the home with the Child
Name
Gender
DOB
Relationship to Child
Select One
Select One
Select One
Select One
Select One
Select One
Child’s Mental Health / Medical Issues:
Current DSM-IV Diagnosis
Date:
By Whom:
AXIS I:
AXIS II
AXIS III:
AXIS IV:
AXIS V: Current GAF:
Highest in past 6 months:
Current And Past Behavioral Health Treatment Providers / Agencies (DCF, Probation, Mental Health, Etc.)
Name of Provider / Agency:
Types of Services:
Dates of Services:
Phone:
Page 2 of 2
Medical Personnel Contact Information
Child’s Psychiatrist:
Phone:
Child’s Therapist
Phone:
Child’s Pediatrician:
Phone:
Does the child take any medications (for physical and/or behavioral health reasons?):
Yes
No
Unknown
If yes, please list the medications:
Other Agencies / Programs Involved with child:
List Services provided:
List Any Current Referrals To Other Programs:
FAMILY AVAILABILITY: Please list the times/days of the week the family could be available for sessions
Afternoons (before 5:00 p.m.)
Evenings (after 5:00 p.m.)
School Information
Name of School:
Town:
Contact Person:
Phone:
Special Education:
Yes
No
Full Scale IQ (if known)
Reason for Referral:
Trauma History
Have any family members been exposed to any of the following traumatic experiences? (check all that apply and indicate which family member it pertains to):
Attachment Disruptions / Multiple Placements:
Domestic Violence:
Physical Abuse:
Sexual Abuse:
Significant Loss:
Community Violence or Victimization:
Other (please Specify):
Unknown:
Please Describe Family’s Strengths (Interpersonal, Community Interested, other):
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