Form DCF-461 "Medical Screening for Placement" - Connecticut

What Is Form DCF-461?

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, 2017;
  • 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-461 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-461 "Medical Screening for Placement" - Connecticut

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Connecticut Department of Children and Families
MEDICAL SCREENING FOR PLACEMENT
DCF-461
3/17 (Rev.)
Page 1 of 1
DATE:
TO:
CCMC Emergency Room Attending Physicians
Fredericka Wolman, MD (fredericka.wolman@ct.gov)
FROM:
Department of Children and Families (DCF) Director of Pediatrics
RE:
Please give this form to the Patient’s Authorized Representative when complete
Thank you in advance for caring for this DCF youth on parole ("the Patient") who has been in the
community on his or her own since running away from placement (or in a similar unsafe situation).
This examination is necessary to assess for acute medical issues, need for detoxification from
substances, and need for urgent medical care before the Patient can be admitted or re-admitted
a residential facility which has limited medical coverage. Please be aware that the toxicology
screen will only be used for clinical reasons (i.e., treatment) as opposed to legal purposes.
In addition to your standard Emergency Room Assessment, we ask that you:
assess the Patient's sexual history, including history of consensual or nonconsensual
intercourse while AWOL;
fully examine the Patient's skin to look for trauma markings, bruises, lesions, rashes and
infestations, recent tattoos, and needle marks or other indications of drug abuse;
perform a urine toxicology screen and communicate the results to the Patient's
Authorized Representative; and
take a full medication history and provide necessary prescriptions.
DCF is aware that that the tests and examinations that the Patient receives from Connecticut
Children’s Medical Center (“Connecticut Children’s") to determine whether the Patient is at risk for
imminent alcohol or drug withdrawal (the “Tests”) may not be conclusive. The Patient may still
experience alcohol or drug withdrawal after the Patient is discharged from Connecticut Children’s
even if the Tests conclude otherwise.
Medical Disposition:
Cleared for admission to emergency placement or return to prior placement
Cleared for admission with need to f/u for further evaluation of the following:
Provider Name:
Address:
E-mail:
Phone:
Connecticut Department of Children and Families
MEDICAL SCREENING FOR PLACEMENT
DCF-461
3/17 (Rev.)
Page 1 of 1
DATE:
TO:
CCMC Emergency Room Attending Physicians
Fredericka Wolman, MD (fredericka.wolman@ct.gov)
FROM:
Department of Children and Families (DCF) Director of Pediatrics
RE:
Please give this form to the Patient’s Authorized Representative when complete
Thank you in advance for caring for this DCF youth on parole ("the Patient") who has been in the
community on his or her own since running away from placement (or in a similar unsafe situation).
This examination is necessary to assess for acute medical issues, need for detoxification from
substances, and need for urgent medical care before the Patient can be admitted or re-admitted
a residential facility which has limited medical coverage. Please be aware that the toxicology
screen will only be used for clinical reasons (i.e., treatment) as opposed to legal purposes.
In addition to your standard Emergency Room Assessment, we ask that you:
assess the Patient's sexual history, including history of consensual or nonconsensual
intercourse while AWOL;
fully examine the Patient's skin to look for trauma markings, bruises, lesions, rashes and
infestations, recent tattoos, and needle marks or other indications of drug abuse;
perform a urine toxicology screen and communicate the results to the Patient's
Authorized Representative; and
take a full medication history and provide necessary prescriptions.
DCF is aware that that the tests and examinations that the Patient receives from Connecticut
Children’s Medical Center (“Connecticut Children’s") to determine whether the Patient is at risk for
imminent alcohol or drug withdrawal (the “Tests”) may not be conclusive. The Patient may still
experience alcohol or drug withdrawal after the Patient is discharged from Connecticut Children’s
even if the Tests conclude otherwise.
Medical Disposition:
Cleared for admission to emergency placement or return to prior placement
Cleared for admission with need to f/u for further evaluation of the following:
Provider Name:
Address:
E-mail:
Phone: