Form DCF-449 "Permission to Place and Treat Child Placed Under Voluntary Services Program" - Connecticut

What Is Form DCF-449?

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 September 1, 2015;
  • 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-449 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-449 "Permission to Place and Treat Child Placed Under Voluntary Services Program" - Connecticut

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Connecticut Department of Children and Families
PERMISSION TO PLACE AND TREAT CHILD PLACED UNDER VOLUNTARY SERVICES PROGRAM
DCF-449
9/15 (Rev.)
Page 1 of 1
This is an agreement between the Department of Children and Families (DCF) and the parent(s) or guardian(s) of:
LAST Name of Child:
FIRST Name of Child:
DOB:
LINK#:
As legal guardian(s) of the above child, and as a parent(s) who retains all parental rights over said child, I/we request and agree to his/her
voluntary placement under the care and supervision of DCF.
 
I/We authorize routine tests and treatment that DCF considers necessary for the proper welfare of my/our child, including psychiatric, medical
and dental treatment. I/We also authorize DCF, in my/our absence (after making reasonable but unsuccessful attempts to contact me/us) to
authorize emergency treatment, including surgery, to protect the life and well-being of my/our child.
I/We agree to the following:
visit my/our child as arranged by me/us and the treatment team
actively participate in the case planning for my/our child toward the anticipated goal of reunification with his/her family
actively participate in any/all treatment work/sessions for my/our child, as recommended by the treatment team
notify DCF should I/we plan to remove my/our child from DCF care
provide DCF with information related to my/our child’s health and welfare, and authorize the release of all relevant information and
reports to DCF and authorize DCF to share information about my/our child with those providing health, education or other services for
the welfare of my/our child
keep DCF informed of our current whereabouts and contact information, both for routine and emergency purposes
I/We understand that we may be expected to make financial contributions toward the cost of care for my/our child, if determined
capable by the State of Connecticut, Department of Administrative Services Bureau of Collection Services
Parental restrictions:
Parental medical coverage(s):
The Department of Children and Families will:
upon your request, return your child to you within 24 hours, unless an emergency exists
provide care for your child in the least restrictive and most appropriate treatment setting available to DCF
arrange for you to visit with your child
actively participate in the case planning for your child toward the anticipated goal of reunification with his/her family
make arrangements with you for the medical, dental and optical care of your child
notify you when DCF determines that it is appropriate to return your child to you
Name of Parent 1/Guardian 1:
Signature of Parent 1/Guardian 1:
Date:
Work #:
Home/Cell #:
Address (No. and Street):
City:
State:
Zip:
Name of Parent 2Guardian 12:
Signature of Parent 2/Guardian 2:
Date:
Work #:
Home/Cell #:
Address (No. and Street - if different from address above):
City:
State:
Zip:
Name of Social Worker
Signature of Social Worker:
Date:
Work #:
Cell #:
Name of Social Work Supervisor
Signature of Social Work Supervisor:
Date:
Work #:
Cell #:
DCF Office and Address:
Please Select DCF Office
Connecticut Department of Children and Families
PERMISSION TO PLACE AND TREAT CHILD PLACED UNDER VOLUNTARY SERVICES PROGRAM
DCF-449
9/15 (Rev.)
Page 1 of 1
This is an agreement between the Department of Children and Families (DCF) and the parent(s) or guardian(s) of:
LAST Name of Child:
FIRST Name of Child:
DOB:
LINK#:
As legal guardian(s) of the above child, and as a parent(s) who retains all parental rights over said child, I/we request and agree to his/her
voluntary placement under the care and supervision of DCF.
 
I/We authorize routine tests and treatment that DCF considers necessary for the proper welfare of my/our child, including psychiatric, medical
and dental treatment. I/We also authorize DCF, in my/our absence (after making reasonable but unsuccessful attempts to contact me/us) to
authorize emergency treatment, including surgery, to protect the life and well-being of my/our child.
I/We agree to the following:
visit my/our child as arranged by me/us and the treatment team
actively participate in the case planning for my/our child toward the anticipated goal of reunification with his/her family
actively participate in any/all treatment work/sessions for my/our child, as recommended by the treatment team
notify DCF should I/we plan to remove my/our child from DCF care
provide DCF with information related to my/our child’s health and welfare, and authorize the release of all relevant information and
reports to DCF and authorize DCF to share information about my/our child with those providing health, education or other services for
the welfare of my/our child
keep DCF informed of our current whereabouts and contact information, both for routine and emergency purposes
I/We understand that we may be expected to make financial contributions toward the cost of care for my/our child, if determined
capable by the State of Connecticut, Department of Administrative Services Bureau of Collection Services
Parental restrictions:
Parental medical coverage(s):
The Department of Children and Families will:
upon your request, return your child to you within 24 hours, unless an emergency exists
provide care for your child in the least restrictive and most appropriate treatment setting available to DCF
arrange for you to visit with your child
actively participate in the case planning for your child toward the anticipated goal of reunification with his/her family
make arrangements with you for the medical, dental and optical care of your child
notify you when DCF determines that it is appropriate to return your child to you
Name of Parent 1/Guardian 1:
Signature of Parent 1/Guardian 1:
Date:
Work #:
Home/Cell #:
Address (No. and Street):
City:
State:
Zip:
Name of Parent 2Guardian 12:
Signature of Parent 2/Guardian 2:
Date:
Work #:
Home/Cell #:
Address (No. and Street - if different from address above):
City:
State:
Zip:
Name of Social Worker
Signature of Social Worker:
Date:
Work #:
Cell #:
Name of Social Work Supervisor
Signature of Social Work Supervisor:
Date:
Work #:
Cell #:
DCF Office and Address:
Please Select DCF Office