Form DCF-334 "Adoption Resource Exchange (Are) Family Registration" - Connecticut

What Is Form DCF-334?

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

Download a fillable version of Form DCF-334 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-334 "Adoption Resource Exchange (Are) Family Registration" - Connecticut

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Department of Children and Families
ADOPTION RESOURCE EXCHANGE (ARE) FAMILY REGISTRATION
DCF-334
6/17 (Rev.)
Page 1 of 4
ARE USE ONLY
Date
Support Worker Name:
Registered:
Support Worker Phone:
Support Worker E-Mail:
FAMILY
Parent 1
Parent 2
Last Name:
First Name:
Last Name:
First Name:
DOB:
Phone:
DOB:
Phone:
E-mail:
E-Mail:
Race:
Ethnicity:
Race:
Ethnicity:
Please Select One
Please Select One
Please Select One
Please Select One
Address: (No. and Street):
City
State
Zip
Connecticut
If “yes”, what type of animal(s)?:
Smokers in the home?:
Yes
No
Pets on the Home?:
Yes
No
CHILDREN IN HOME
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Select One
Please Select One
Please Select One
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Please Select One
Select One
Please Select One
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Please Select One
Select One
Please Select One
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Select One
Please Select One Please Select One
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Please Select One Please Select One
Select One
TYPE OF CHILD/CHILDREN FAMILY WILL CONSIDER
Gender(s):
Female
Male
Any gender, Identity/expression-it doesn’t matter
Age Range:
Birth-to-5 years
6 to 12
13 to 18
Race/Ethnicity:
African American / Black
African American / Caucasian
African American / Latino
Asian
American Indian/Alaskan Native
Caucasian/White
Hispanic
Pacific Islander
Other:
Will you consider a Sibling Group?:
Yes
No
If “Yes”, number of Siblings that the Family will consider:
Gender Make-up of Sibling group?:
Female
Male
Other:
Any gender, Identity/expression-it doesn’t matter
Will you consider a “Legal Risk” adoption?
Yes
No
If ‘Yes”, what level(s) of legal risk?
Termination has been granted, but termination order has been appealed.
Case is filed in court, but hearing is contested, and a series of continuances is expected.
You would provide foster care to a child for whom the department plans to file a termination petition with the expectation you would adopt a child if the child
becomes legally free.
Will you consider an “Open” adoption?
Yes
No.
If ‘Yes”, what type of open adoption would you consider? (Check all that apply):
Letters/Gifts
Visit with Bio/Sibling/Relative
Visit with Bio Parents
Other:
Department of Children and Families
ADOPTION RESOURCE EXCHANGE (ARE) FAMILY REGISTRATION
DCF-334
6/17 (Rev.)
Page 1 of 4
ARE USE ONLY
Date
Support Worker Name:
Registered:
Support Worker Phone:
Support Worker E-Mail:
FAMILY
Parent 1
Parent 2
Last Name:
First Name:
Last Name:
First Name:
DOB:
Phone:
DOB:
Phone:
E-mail:
E-Mail:
Race:
Ethnicity:
Race:
Ethnicity:
Please Select One
Please Select One
Please Select One
Please Select One
Address: (No. and Street):
City
State
Zip
Connecticut
If “yes”, what type of animal(s)?:
Smokers in the home?:
Yes
No
Pets on the Home?:
Yes
No
CHILDREN IN HOME
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Select One
Please Select One
Please Select One
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Please Select One
Select One
Please Select One
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Please Select One
Select One
Please Select One
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Select One
Please Select One Please Select One
Last Name:
First Name:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Please Select One Please Select One
Select One
TYPE OF CHILD/CHILDREN FAMILY WILL CONSIDER
Gender(s):
Female
Male
Any gender, Identity/expression-it doesn’t matter
Age Range:
Birth-to-5 years
6 to 12
13 to 18
Race/Ethnicity:
African American / Black
African American / Caucasian
African American / Latino
Asian
American Indian/Alaskan Native
Caucasian/White
Hispanic
Pacific Islander
Other:
Will you consider a Sibling Group?:
Yes
No
If “Yes”, number of Siblings that the Family will consider:
Gender Make-up of Sibling group?:
Female
Male
Other:
Any gender, Identity/expression-it doesn’t matter
Will you consider a “Legal Risk” adoption?
Yes
No
If ‘Yes”, what level(s) of legal risk?
Termination has been granted, but termination order has been appealed.
Case is filed in court, but hearing is contested, and a series of continuances is expected.
You would provide foster care to a child for whom the department plans to file a termination petition with the expectation you would adopt a child if the child
becomes legally free.
Will you consider an “Open” adoption?
Yes
No.
If ‘Yes”, what type of open adoption would you consider? (Check all that apply):
Letters/Gifts
Visit with Bio/Sibling/Relative
Visit with Bio Parents
Other:
Page 2 of 4
Are you able to take emergency placements?
Yes
No.
If “Yes”, what are your immediate daycare arrangements?:
SOCIAL/EMOTIONAL ISSUES FOR THE CHILD
What degree(s) of social/emotional issues are you willing to consider?
None
Mild
Moderate
Severe
Please check all areas that you could consider:
Adjustment Disorder
Attention Deficit-Hyperactivity Disorder
Autism
Bipolar Disorder
Borderline Personality Disorder
Conduct Disorder
Depression
Eating Disorder (Anorexia/Bulimia)
Generalized Anxiety Disorder
Oppositional Defiant Disorder
Schizophrenia
Reactive-Attachment Disorder
Post-Traumatic Stress Disorder
Other (specify):
MEDICAL/PHYSICAL ISSUES FOR THE CHILD:
What degree(s) of medical/physical issues are you willing to consider?
None
Mild
Moderate
Severe
Please check all areas that you could consider:
Adaptive Equipment (Wheelchairs, Walkers, etc.)
Asthma Classification
Burn Care
Complex Multiple Drug Regimen
Diabetes
Down Syndrome
Drug Dependent
Drug Exposed
Failure to Thrive
Fetal Alcohol Effect
Hearing Loss
Fetal Alcohol Syndrome
Invasive Medical Care (Feeding Tubes, etc.)
Hydrocephalus
Premature Newborn
Terminal Illness
Seizure Disorder
Shaken Baby
Spina Bifida
Visual Impairment
Other (specify):
LEARNING/INTELLECTUAL ISSUES FOR THE CHILD:
What degree(s) of learning/intellectual issues are you willing to consider?
None
Mild
Moderate
Severe
Please check all areas that you could consider:
Developmental Disabilities (Mental Retardation; PDD)
Motor Skills Disorder
Speech Disorder
Expressive Language Disorder
Non-Specific Learning Disability
Receptive Language Disability
Lead Poisoning
Other (specify):
BEHAVIORAL ISSUES FOR THE CHILD:
Traumatized children often display challenging behaviors. Please indicate the areas and degree(s) that you could consider:
None
Mild
Moderate
Severe
Please check all areas that you could consider:
Chronic Runaway
Lies
Sets Fire
Destroys Property
Harms Animals
Physically Aggressive
Steals
Self-Injurious
Other (specify):
Will you consider a child with the following issues: (Please check all that apply.)
Child has been sexually abused.
Child may need on-going therapy.
Child was born as a result of an incestuous relationship
Child is sexually acting out.
Child has been in a residential care setting.
Other (specify):
Will you consider a child with these issues in his/her parents' background? (Please check all that apply.)
Alcohol
Abuse
Substance se
Developmental Disabilities (Mental Retardation)
Intimate Partner Violence
Mental Illness
Other (specify):
Page 3 of 4
SIGNATURES
Signature of Parent 1
Signature of Parent 2
Date:
Name of Social Worker:
Signature of Social Worker
Date:
Name of Social Work Supervisor:
Signature of Social Work Supervisor
Date:
Name of Agency:
Telephone:
Address:
City:
State:
Zip:
FAMILY REGISTRATION GLOSSARY
This glossary was created as an addendum to the revised (6-08) family registration form to help clarify some of the more common issues facing children who are
adopted from foster care. The information in this document was obtained through internet and DSM IV research. In no way should this guide be considered an exact
means of diagnosing a particular child nor should it be considered all inclusive. Should a family express a willingness to care for a child with any type of challenging
behavior, they should be encouraged to further research and discuss a particular child's diagnosis and issues with professionals who have expertise in this area.
S
/ E
I
F
T
C
OCIAL
MOTIONAL
SSUES
OR
HE
HILD
Adjustment Disorder: is a condition that occurs when a person is unable to cope with, or adjust to, a particular source of stress, such as a major life change, loss, or
event.
Attention Deficit- Hyperactivity Disorder (ADHD): is a condition in which a person has trouble paying attention and focusing on tasks, experiences trouble sitting
still for even a short time, and often acts before thinking. It may begin in early childhood and can continue into adulthood.
Autism: is a complex developmental disability that typically appears during the first three years of life. It affects the normal functioning of the brain impacting
development in the areas of social interaction and communication skills. Examples of behaviors include repeated body rocking, unusual attachments to objects, and
getting very upset when routines change. The range of impact this disability can have on a child's functioning can show itself in many forms ranging from very mild to
very severe.
Bipolar Disorder: is a mental health condition characterized by extreme changes in mood, from mania to depression. Between these mood swings, a person with
Bipolar disorder may experience normal moods. "Manic" describes an increasingly restless, energetic, talkative, reckless, powerful, euphoric period. "Depression"
describes the opposite mood -- sadness, crying, sense of worthlessness, loss of energy, loss of pleasure, sleep problems.
Borderline Personality Disorder: is a mental health condition that causes unstable emotions, impulsiveness, relationship problems, and an unstable self-image.
Features of borderline personality disorder include aggressive behavior, difficulty controlling emotions and impulses, problems with unstable and intense relationships,
a low sense of self-worth, and frantic anxiety about being left alone (abandoned).
Conduct Disorder: is a serious behavioral and emotional disorder that can occur in children and teens. Negative behavior is considered to be a conduct disorder
when it is long-lasting and when it violates the rights of others, goes against accepted norms of behavior and disrupts the child's or families everyday life. Children with
conduct disorder often are unable to appreciate how their behavior can hurt others and generally have little guilt or remorse about hurting others.
D
D
EVELOPMENTAL
ISABILITIES
Speech and Language Delays: refers to delays in the ability to formulate words and comprehend meaning. Speech refers to verbal expression, including the way
words are formed. Language is a broader system of expressing and receiving information, such as being able to understand directions.
Motor Skills Delays: refers to delays related to the development of gross motor skills such as playing ball, or fine motor skills, such as coloring.
Social and Emotional Delays: refers to a child's difficulty interacting with adults or other children. This difficulty is often first noticed in pre-school aged children.
Cognitive Delays: refers to difficulties in thinking and processing skills.
Depression: is a mental health condition in which feelings of sadness persist and interfere with a child or adolescent’s ability to function.
Eating Disorders (Anorexia / Bulimia): Anorexia is an eating disorder characterized by low body weight and body image distortion with an obsessive fear of gaining
weight. Bulimia is an eating disorder characterized by recurrent binge eating, followed by compensatory behaviors, referred to as "purging."
Generalized Anxiety Disorder: is a mental health condition which occurs when someone feels worried and stressed about many everyday events and activities.
Often the things worried about are, in reality, are small or not important. This type of worry disrupts a person's life on most days.
Oppositional Defiant Disorder: (ODD) is a condition in which a child displays an ongoing pattern of uncooperative, defiant, hostile and annoying behavior toward
people in authority. The child's behavior often disrupts the child's normal daily activities, including activities within the family and at school.
Post-Traumatic Stress Disorder: (PTSD) is a mental health condition which can occur after you have been through or experience a traumatic event. A traumatic
event is something horrible and scary that you see or that happens to you. During this type of event, you think that your life or others' lives are in danger. You may feel
afraid or feel that you have no control over what is happening.
Reactive Attachment Disorder (RAD): is a mental health condition found in children who have received grossly negligent care and who do not form a healthy
emotional attachment with their primary caregivers before age five. The absence of emotional warmth during the first few years of life can negatively affect a child's
entire life.
Schizophrenia: is a chronic brain disorder with symptoms which include distorted perceptions of reality, hallucinations and delusions, illogical thinking and flat or
blunted emotions.
Page 4 of 4
M
/ P
I
F
T
C
EDICAL
HYSICAL
SSUES
OR
HE
HILD
Asthma: Asthma is an inflammatory disorder of the airways, which causes attacks of wheezing, shortness of breath, chest tightness, and coughing. Asthma can range
from mild to life-threatening.
Diabetes: is a physical condition in which your blood glucose, or sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the
glucose get into your cells to give them energy. With Type 1 diabetes, your body does not make insulin. With Type 2 diabetes, the more common type, your body does
not make or use insulin well. Without enough insulin, the glucose stays in your blood.
Down Syndrome: is a set of mental and physical symptoms that result from having an extra copy of chromosome 21. Even though people with Down syndrome may
have some physical and mental features in common, symptoms of Down syndrome can range from mild to severe.
Drug Dependent Infant: is an infant who is exposed to drugs in utero and who tests positive for drugs at birth. Such a child will need to be withdrawn from the drugs
and may sometimes need medication. Withdrawal symptoms may range from mild to severe and include hyperactivity, sleep and feeding problems, severe fussiness,
breathing problems, diarrhea, vomiting, and convulsions. Long-term development may also be affected.
Drug Exposed: is a child who was exposed to drugs in utero, however did not test positive at birth.
Failure to Thrive: is a medical term which denotes poor weight gain and physical growth failure over an extended period of time in infancy. It does not automatically
imply abnormal intellectual, social, or emotional development.
Fetal Alcohol Syndrome (FAS): is a condition that results from prenatal exposure to excessive alcohol consumption. Defects resulting from FAS are irreversible and
can include mild to severe physical mental and behavioral challenges.
Hydrocephalus: is a condition resulting from the buildup of too much cerebrospinal fluid in the brain. Normally, this fluid cushions your brain. However, when you
have too much it puts harmful pressure on your brain. There are two kinds of hydrocephalus; congenital hydrocephalus and acquired hydrocephalus. Treatment
usually involves surgery to insert a shunt.
I
M
C
NVASIVE
EDICAL
ARE
Feeding Tubes: a feeding tube is a small, soft, plastic tube placed through the nose (NG) or mouth (OG) into the stomach. These tubes are used to provide feedings
and medications into the stomach until a baby can take food by mouth.
Tracheotomy: necessary surgical procedures on the neck to open a direct airway through an incision in the trachea (the windpipe).
Premature Newborn: (also known as preterm birth) the birth of a baby before the standard period of pregnancy is completed. In most systems of human pregnancy,
prematurity is considered to occur when the baby is born sooner than 37 weeks gestation.
Seizure Disorder: is a sudden attack of brain activity that causes a loss of control over movement resulting in a seizure/convulsion. The attacks can last anywhere
from a few seconds to several minutes. People of any age can be affected. The most common type of seizure is idiopathic epilepsy, a form of epilepsy whose cause
is not known.
Shaken Baby Syndrome: is a serious brain injury that occurs when a baby is violently shaken or slammed against a hard object.
Spina Bifida: is a group of disorders characterized by the failure of the closure or fusion of the posterior arch (back part) of the vertebrae during the first month of
development. The bony deficit can occur with or without neurological injury to the spinal cord and associated spinal nerves.
L
/I
I
EARNING
NTELLECTUAL
SSUES
Developmental Disabilities (Mental Retardation): is a mental and developmental condition that is characterized by a significantly lower than average level of general
intellectual functioning. It is characterized by deficits in adaptive functioning. Adaptive functioning includes communication, social activities, relationship building and
daily living skills.
Pervasive Developmental Disorders (PDD): are a group of conditions originating in childhood that involve serious impairment in several areas, including physical,
behavioral, cognitive, social, and language development.
Autism: is the most serious form of PDD, a condition characterized by severely impaired social interaction, communication, and abstract thought, and often manifested
by stereotyped and repetitive behavior patterns.
Rett's disorder: is a condition characterized by physical, mental, and social impairment. This syndrome appears in girls only, usually between the ages of five months
and four years. It involves impairment of coordination, repetitive movements, a slowing of head growth, severe or profound mental retardation, and impaired social and
communication skills.
Asperger's Disorder: is an autism spectrum disorder more commonly found in boys than girls. Children with this disorder have many of the same social and behavioral
impairments as autism, except for difficulties with language. They lack normal tools of social interaction, such as the ability to meet someone else's gaze, use
appropriate body language and gestures, or react to another person's thoughts and feelings. Behavioral impairments include the repetitive, stereo-typed motions and
rigid adherence to routines that are characteristic of autism.
Expressive Language Disorder: is a childhood disorder resulting in an individual having problems expressing themselves using verbal language. Developmental
expressive language disorder does not
Page of 4