Form DCF-357 "Physician's Statement for Foster Care or Adoptive Applicant" - Connecticut

What Is Form DCF-357?

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, 2016;
  • 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-357 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-357 "Physician's Statement for Foster Care or Adoptive Applicant" - Connecticut

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Department of Children and Families
PHYSICIAN’S STATEMENT FOR FOSTER CARE OR ADOPTIVE APPLICANT
DCF-357
3/16 (Rev.)
Page 1 of 2
AUTHORIZATION TO RELEASE CONDIENTIAL INFORMATION
I hereby authorize
To release to the Department of Children and Families
The information requested below regarding my minor child as required by the Department policies for Probate Court Custodian / Guardian
applicants and their child.
Name of Child:
Signature of Applicant:
Date:
Address: (No. and Street)
City
State
Zip
Applicant / or Child’s Name:
DOB:
Date of Last Examination:
Weight:
Height:
Eyes:
Hearing:
Blood Pressure:
Heart:
Date:
Lungs:
Neuro-Muscular:
Chest X-Ray:
Date:
Results
Blood Serology:
Date:
Results
Urinalysis:
Date:
Results
How long have you known the applicant (or Child)?:
Has the applicant (or Child) had any significant chronic or active medical, familial or psychiatric conditions?
Yes
No.
If “Yes”, please describe:
Has the applicant (or Child) had any significant hospital admissions?
Yes
No.
If “Yes”, please describe:
Please give your impression of the applicant’s (or child’s) health status, both physical and emotional; general prognosis for
continued well-being
Do you consider the applicant’s physical and emotional condition satisfactory to provide foster care or adopt a child?
Yes
No.
If “No”, please describe:
Is the applicant (or child) free from communicable disease?
Yes
No.
If “No”, please describe:
Name of Physician
Signature of Physician
Address:
City
State
Zip
Phone:
Date:
NOTE: This report should be mailed directly by the examining physician to the Department of Children and Families office listed below:
Attention:
DCF Office and Address:
Date:
Please Select DCF Office
Department of Children and Families
PHYSICIAN’S STATEMENT FOR FOSTER CARE OR ADOPTIVE APPLICANT
DCF-357
3/16 (Rev.)
Page 1 of 2
AUTHORIZATION TO RELEASE CONDIENTIAL INFORMATION
I hereby authorize
To release to the Department of Children and Families
The information requested below regarding my minor child as required by the Department policies for Probate Court Custodian / Guardian
applicants and their child.
Name of Child:
Signature of Applicant:
Date:
Address: (No. and Street)
City
State
Zip
Applicant / or Child’s Name:
DOB:
Date of Last Examination:
Weight:
Height:
Eyes:
Hearing:
Blood Pressure:
Heart:
Date:
Lungs:
Neuro-Muscular:
Chest X-Ray:
Date:
Results
Blood Serology:
Date:
Results
Urinalysis:
Date:
Results
How long have you known the applicant (or Child)?:
Has the applicant (or Child) had any significant chronic or active medical, familial or psychiatric conditions?
Yes
No.
If “Yes”, please describe:
Has the applicant (or Child) had any significant hospital admissions?
Yes
No.
If “Yes”, please describe:
Please give your impression of the applicant’s (or child’s) health status, both physical and emotional; general prognosis for
continued well-being
Do you consider the applicant’s physical and emotional condition satisfactory to provide foster care or adopt a child?
Yes
No.
If “No”, please describe:
Is the applicant (or child) free from communicable disease?
Yes
No.
If “No”, please describe:
Name of Physician
Signature of Physician
Address:
City
State
Zip
Phone:
Date:
NOTE: This report should be mailed directly by the examining physician to the Department of Children and Families office listed below:
Attention:
DCF Office and Address:
Date:
Please Select DCF Office