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

Form DCF-357 or the "Physician's Statement For Foster Care Or Adoptive Applicant" is a form issued by the Connecticut State Department of Children and Families.

The form was last revised in March 1, 2016 and is available for digital filing. Download an up-to-date Form DCF-357 in PDF-format down below or look it up on the Connecticut State Department of Children and Families Forms website.

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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
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