Form DCF-779-VS "Notice at Age of Majority Voluntary Services Clients" - Connecticut

What Is Form DCF-779-VS?

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 January 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 printable version of Form DCF-779-VS 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-779-VS "Notice at Age of Majority Voluntary Services Clients" - Connecticut

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DCF-779-VS
State of Connecticut
01/2015 (New)
Department of Children and Families
NOTICE AT AGE OF MAJORITY
VOLUNTARY SERVICES CLIENTS
Name of Youth:
DOB:
Address:
Phone:
City, State & Zip:
LINK#:
th
Within the next three months you will reach your 18
birthday. You may continue to receive Voluntary
st
Services from the Department of Children and Families until your 21
birthday as long as DCF, in its
discretion, determines that you will benefit from further care and support from DCF, you consent to
continue to receive services, and you cooperate with the services set out in your case plan. If DCF
determines that you cannot benefit from further care and support, you will be provided with written
notice and have the right to an administrative hearing.
I WISH TO:
Voluntarily continue by participating in services offered by DCF and set forth in my case plan.
Transfer to:
Department of Mental Health and Addiction Services
Department of Developmental Services
______________________________________ ____________________________________________
Signature of Youth
Date
Signature of DCF Social Worker
Date
☐ Leave DCF care on my 18
th
OR
birthday, I understand that DCF will terminate money payments
and placement services on that date.
Date to review Adolescent Transition Plan: ________________________________
______________________________________ ____________________________________________
Signature of Youth
Date
Signature of DCF Social Worker
Date
____________________________________________
Signature of DCF Youth’s Attorney of GAL Date
Faxed to DCF Medical Assistance Unit (203) 427-2880
DCF-779-VS
State of Connecticut
01/2015 (New)
Department of Children and Families
NOTICE AT AGE OF MAJORITY
VOLUNTARY SERVICES CLIENTS
Name of Youth:
DOB:
Address:
Phone:
City, State & Zip:
LINK#:
th
Within the next three months you will reach your 18
birthday. You may continue to receive Voluntary
st
Services from the Department of Children and Families until your 21
birthday as long as DCF, in its
discretion, determines that you will benefit from further care and support from DCF, you consent to
continue to receive services, and you cooperate with the services set out in your case plan. If DCF
determines that you cannot benefit from further care and support, you will be provided with written
notice and have the right to an administrative hearing.
I WISH TO:
Voluntarily continue by participating in services offered by DCF and set forth in my case plan.
Transfer to:
Department of Mental Health and Addiction Services
Department of Developmental Services
______________________________________ ____________________________________________
Signature of Youth
Date
Signature of DCF Social Worker
Date
☐ Leave DCF care on my 18
th
OR
birthday, I understand that DCF will terminate money payments
and placement services on that date.
Date to review Adolescent Transition Plan: ________________________________
______________________________________ ____________________________________________
Signature of Youth
Date
Signature of DCF Social Worker
Date
____________________________________________
Signature of DCF Youth’s Attorney of GAL Date
Faxed to DCF Medical Assistance Unit (203) 427-2880