Form DCF-354 "Application for Foster Care or Adoption" - Connecticut

What Is Form DCF-354?

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 December 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-354 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-354 "Application for Foster Care or Adoption" - Connecticut

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Connecticut Department of Children and Families
APPLICATION FOR FOSTER CARE OR ADOPTION
DCF-354
1216 (Rev.)
Page 1 of 7
FOR DCF USE ONLY
Assigned Social Worker:
Foster Care
CMS
Date:
Regular
VPS
Date:
Independent
DCF Office
LINK
Date:
Special Study
Please Select DCF Office
Day Care License (DPH)
Date:
Adoption
Telephone:
PARENT 1
PARENT 2
LAST Name:
FIRST Name:
Middle:
LAST Name:
FIRST Name:
Middle:
Maiden Name (if applicable):
AKA (if applicable):
Maiden Name (if applicable):
AKA (if applicable):
Birthplace:
SS #:
Driver’s License# :
Birthplace:
SS #:
Driver’s License #:
Language:
Military Service:
Language:
Military Service:
CURRENT ADDRESS and PHONE #
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
Address: (No. and Street):
City:
State:
Zip:
Years at current address:
List Previous Address(es) (within the last 5 years if applicable):
List Previous Address(es) (within the last 5 years if applicable):
CURRENT MARRIAGE OR RELATIONSHIP:
Date of Current Marriage:
Place where Marriage occurred:
Date started living together (if not married):
PREVIOUS MARRIAGE(S) or RELATIONSHIP(S)
Name of Previous Spouse/Partner:
Start Date:
End Date:
Name of Previous Spouse/Partner:
Start Date:
End Date:
REASON:
Divorce
Separation
Death
REASON:
Divorce
Separation
Death
Name of Previous Spouse/Partner:
Start Date:
End Date:
Name of Previous Spouse/Partner:
Start Date:
End Date:
REASON:
Divorce
Separation
Death
REASON:
Divorce
Separation
Death
Name of Previous Spouse/Partner:
Start Date:
End Date:
Name of Previous Spouse/Partner:
Start Date:
End Date:
REASON:
Divorce
Separation
Death
REASON:
Divorce
Separation
Death
EMPLOYMENT INFORMATION
Name of Employer:
Start Date:
Name of Employer:
Start Date:
Position:
Employer Phone:
Working Hours:
Position:
Employer Phone:
Working Hours:
Name of Employer (second job):
Start Date:
Name of Employer (second job):
Start Date:
Position:
Employer Phone:
Working Hours:
Position:
Employer Phone:
Working Hours:
Connecticut Department of Children and Families
APPLICATION FOR FOSTER CARE OR ADOPTION
DCF-354
1216 (Rev.)
Page 1 of 7
FOR DCF USE ONLY
Assigned Social Worker:
Foster Care
CMS
Date:
Regular
VPS
Date:
Independent
DCF Office
LINK
Date:
Special Study
Please Select DCF Office
Day Care License (DPH)
Date:
Adoption
Telephone:
PARENT 1
PARENT 2
LAST Name:
FIRST Name:
Middle:
LAST Name:
FIRST Name:
Middle:
Maiden Name (if applicable):
AKA (if applicable):
Maiden Name (if applicable):
AKA (if applicable):
Birthplace:
SS #:
Driver’s License# :
Birthplace:
SS #:
Driver’s License #:
Language:
Military Service:
Language:
Military Service:
CURRENT ADDRESS and PHONE #
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
Address: (No. and Street):
City:
State:
Zip:
Years at current address:
List Previous Address(es) (within the last 5 years if applicable):
List Previous Address(es) (within the last 5 years if applicable):
CURRENT MARRIAGE OR RELATIONSHIP:
Date of Current Marriage:
Place where Marriage occurred:
Date started living together (if not married):
PREVIOUS MARRIAGE(S) or RELATIONSHIP(S)
Name of Previous Spouse/Partner:
Start Date:
End Date:
Name of Previous Spouse/Partner:
Start Date:
End Date:
REASON:
Divorce
Separation
Death
REASON:
Divorce
Separation
Death
Name of Previous Spouse/Partner:
Start Date:
End Date:
Name of Previous Spouse/Partner:
Start Date:
End Date:
REASON:
Divorce
Separation
Death
REASON:
Divorce
Separation
Death
Name of Previous Spouse/Partner:
Start Date:
End Date:
Name of Previous Spouse/Partner:
Start Date:
End Date:
REASON:
Divorce
Separation
Death
REASON:
Divorce
Separation
Death
EMPLOYMENT INFORMATION
Name of Employer:
Start Date:
Name of Employer:
Start Date:
Position:
Employer Phone:
Working Hours:
Position:
Employer Phone:
Working Hours:
Name of Employer (second job):
Start Date:
Name of Employer (second job):
Start Date:
Position:
Employer Phone:
Working Hours:
Position:
Employer Phone:
Working Hours:
Connecticut Department of Children and Families
APPLICATION FOR FOSTER CARE OR ADOPTION
DCF-354
1216 (Rev.)
Page 2 of 7
EDUCATIONAL BACKGROUND
Highest Grade Completed (including college):
Highest Grade Completed (including college):
Name of High School:
Name of High School:
Name of College (if applicable):
Name of College (if applicable):
Area of Study (if applicable):
Area of Study (if applicable):
EMERGENCY CONTACTS: In case of emergency, list two persons who can be contacted:
Name:
Relationship:
1.
Address: (No. and Street):
City:
State:
Zip:
Home Phone:
Work Phone:
Name:
Relationship:
2.
Address: (No. and Street):
City:
State:
Zip:
Home Phone:
Work Phone:
YOUR HOUSEHOLD
OTHER ADULT MEMBERS LIVING IN THE HOUSEHOLD:
FIRST Name:
MI:
LAST Name:
Maiden (if applicable):
AKA:
DOB:
Relationship to Applicant
Occupation:
FIRST Name:
MI:
LAST Name:
Maiden (if applicable):
AKA:
DOB:
Relationship to Applicant
Occupation:
FIRST Name:
MI:
LAST Name:
Maiden (if applicable):
AKA:
DOB:
Relationship to Applicant
Occupation:
FIRST Name:
MI:
LAST Name:
Maiden (if applicable):
AKA:
DOB:
Relationship to Applicant
Occupation:
FIRST Name:
MI:
LAST Name:
Maiden (if applicable):
AKA:
DOB:
Relationship to Applicant
Occupation:
CHILDREN LIVING IN THE HOUSEHOLD:
FIRST Name:
MI:
LAST Name:
DOB:
School:
Grade:
FIRST Name:
MI:
LAST Name:
DOB:
School:
Grade:
FIRST Name:
MI:
LAST Name:
DOB:
School:
Grade:
FIRST Name:
MI:
LAST Name:
DOB:
School:
Grade:
FIRST Name:
MI:
LAST Name:
DOB:
School:
Grade:
CHILDREN NOT LIVING IN THE HOUSEHOLD WITH YOU (including adult children):
FIRST Name:
MI:
LAST Name:
DOB:
Where They Live now:
FIRST Name:
MI:
LAST Name:
DOB:
Where They Live now:
FIRST Name:
MI:
LAST Name:
DOB:
Where They Live now:
FIRST Name:
MI:
LAST Name:
DOB:
Where They Live now:
FIRST Name:
MI:
LAST Name:
DOB:
Where They Live now:
Connecticut Department of Children and Families
APPLICATION FOR FOSTER CARE OR ADOPTION
DCF-354
1216 (Rev.)
Page 3 of 7
HOW DID YOU FIND OUT ABOUT FOSTER CARE OR ADOPTION?
Newspaper
Phone Book
Radio
Television
Adoptive Parent
Foster Parent
School Flyer
Church
Other: (please specify:
WHY DO YOU WANT TO FOSTER OR ADOPT?
Have you or anyone regularly residing in your home, or any substitute care giver previously applied, or been
Yes
No
licensed, for foster care or adoption by this Department or any other state or private child placing agency?
If ”Yes”, specify when, where, and the resulting action:
Are you, or have you been, a licensed day care provider?
Yes
No
If ”Yes”, specify when, where, and the resulting action:
Have you discussed foster care or adoption with every family member?
Yes
No
If “Yes”, How do your family members feel about foster care or adoption?:
Why do you want to be a foster or adoptive parent?
Have you or any other family member experienced any major life changes in the past year, for instance, death of
Yes
No
a family member, marriage, divorce, birth of a child, adoption of a child, major illness?
If “Yes”, please explain:
Type of Home you live in:
Single Family
Apartment
Mobile Home
Townhouse / Condo
Do you own or rent your home?
Own
Rent
If you rent, please provide the name and address of the landlord. Notification will
Landlord Name:
be made to the landlord of your interest in receiving a child (children) in your home
Address: (No. and Street):
City:
State:
Zip:
Home Phone:
Work Phone:
How many rooms in the home? (Total #l):
How many bedrooms in the home?:
Where will the foster or adoptive child(ren) sleep?:
Do you have a pool, Jacuzzi or hot tub?
Yes
No
Is your water supply public or from a well?
Public
Well
Do you have an auxiliary heating system?
Yes
No
Is your home lead free?
Yes
No
If “Yes”,
Wood
Coal
Other:
Are there any firearms or other dangerous weapons on the property?
Yes
No
If “Yes”, please explain:
Connecticut Department of Children and Families
APPLICATION FOR FOSTER CARE OR ADOPTION
DCF-354
1216 (Rev.)
Page 4 of 7
ANIMALS / PETS
List the kinds of pets in your home:
Do all the animals have current vaccinations?
Yes
No
N/A
How are the pets supervised?:
Do any of the pets exhibit aggressive behavior?
Yes
No
If “Yes” please explain:
ABOUT YOU AND YOUR HOUSEHOLD MEMBERS?
Has either applicant or anyone regularly residing in your home been convicted of injury or risk of injury to a minor or other similar
offenses against a minor; of impairing the morals of a minor or other similar offenses against a minor; of violent crime against a person
Yes
No
or other similar offenses; of the possession, use or sale of controlled substances within the past five (5) years; or of illegal use of a
firearm or other similar offenses? If “Yes”, please explain what happened and when:
Is either applicant or anyone regularly residing in your home awaiting or currently on trial for any of the charges listed above?
Yes
No
If “Yes”, please explain:
Has either applicant or anyone regularly residing in your home had a minor removed from your/their care or custody for reason of child
abuse or neglect; ever had an allegation of child abuse or neglect substantiated; or have a current child abuse or neglect allegation
Yes
No
pending? If “Yes”, please explain:
Has either applicant or anyone regularly residing in your home ever had any motor vehicle violations (including speeding)?
Yes
No
If “Yes”, please explain what happened and when:
Does either applicant or anyone regularly residing in your home have a criminal record?
Yes
No
If “Yes”, please explain what happened and when:
Connecticut Department of Children and Families
APPLICATION FOR FOSTER CARE OR ADOPTION
DCF-354
1216 (Rev.)
Page 5 of 7
Have you, your parents or your children ever received protective services from DCF?
Yes
No
If “Yes”, please provide the circumstances and date(s):
Have you, your parents, your children or other household members experienced intimate partner violence?:
Yes
No
If “Yes”, please provide the date(s):
Were the police involved?:
Yes
No
If “Yes”, please provide the date(s) and explain the situation and parties who were involved:
REFERENCES
Please list the names of three (3) people who can provide references for you and your family. These must be people who have known you and your family for at
least two (2) years. Only one reference can be a relative. Only one reference can be a person who knows just one family or household member. The other
references must know your entire family and/or have seen you (and your partner, if appropriate) interact with children.
If you have a school age child, one reference must be from your child’s teacher or other professional staff person from the school who has worked with you and
your child or another community professional such as a pediatrician or member of the clergy who knows you and your child.
Please include the relationship of these people to you and your family; for example, sister, church friend, child’s teacher, pediatrician, neighbor, etc.
Name:
Relationship:
1.
City:
State:
Zip:
Home Phone:
Work Phone:
Address: (No. and Street):
Name:
Relationship:
2.
Address: (No. and Street):
City:
State:
Zip:
Home Phone:
Work Phone:
Name:
Relationship:
3.
Address: (No. and Street):
City:
State:
Zip:
Home Phone:
Work Phone:
THIS SECTION FOR DCF OFFICE USE ONLY
Type of Reference Letter:
For Each Reference:
Sent by:
Foster Care (Couple)
Date Sent:
Date Received:
Foster Care (Single)
1.
Adoption (Couple)
2.
Worker’s Name:
Adoption (Single)
3.
Special Study Foster Care