Form DCF-1095 "Child Profile for Respite Care" - Connecticut

What Is Form DCF-1095?

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;
  • 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-1095 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

ADVERTISEMENT
ADVERTISEMENT

Download Form DCF-1095 "Child Profile for Respite Care" - Connecticut

1008 times
Rate (4.3 / 5) 60 votes
State of Connecticut
DCF-1095
Department of Children and Families
06/2017 (Rev.)
Page 1 of 2
CHILD PROFILE FOR RESPITE CARE
Licensed Parent: Complete this form and hand to the respite caregiver when leaving a child in respite care.
Child’s Name:
LINK Number:
Date of Birth:
Licensed Parent’s Name and Address:
Phone:
DCF Worker’s Name and Phone:
DCF Social Work Supervisor’s Name and Phone:
DCF CARELINE PHONE NUMBER: 1-800-842-2288
CONNECTICUT ALLIANCE OF FOSTER & ADOPTIVE FAMILIES (CAFAF): (860)-258-3400
CAFAF HELP LINE: 1-888-223-2780 - OPEN 24 HOURS A DAY
Child’s Medical Number:
Name of Plan:
Child’s Physician:
Phone:
Medications: (Must be transported by adults and not put in child’s suitcase. Must be administered only by adults.)
Please list and give the schedule for medications. Does child resist or hide medicines?
Yes
No
Name of Medication
Type of Medication
Medication Schedule
(number of pills, when given, how often)
Any allergies?
Yes
No
(If yes, list)
Any food dislikes?
Yes
No
Any food preferences?
Yes
No
(If yes, list)
(If yes, list)
Activities he or she likes:
Activities to be avoided:
State of Connecticut
DCF-1095
Department of Children and Families
06/2017 (Rev.)
Page 1 of 2
CHILD PROFILE FOR RESPITE CARE
Licensed Parent: Complete this form and hand to the respite caregiver when leaving a child in respite care.
Child’s Name:
LINK Number:
Date of Birth:
Licensed Parent’s Name and Address:
Phone:
DCF Worker’s Name and Phone:
DCF Social Work Supervisor’s Name and Phone:
DCF CARELINE PHONE NUMBER: 1-800-842-2288
CONNECTICUT ALLIANCE OF FOSTER & ADOPTIVE FAMILIES (CAFAF): (860)-258-3400
CAFAF HELP LINE: 1-888-223-2780 - OPEN 24 HOURS A DAY
Child’s Medical Number:
Name of Plan:
Child’s Physician:
Phone:
Medications: (Must be transported by adults and not put in child’s suitcase. Must be administered only by adults.)
Please list and give the schedule for medications. Does child resist or hide medicines?
Yes
No
Name of Medication
Type of Medication
Medication Schedule
(number of pills, when given, how often)
Any allergies?
Yes
No
(If yes, list)
Any food dislikes?
Yes
No
Any food preferences?
Yes
No
(If yes, list)
(If yes, list)
Activities he or she likes:
Activities to be avoided:
Page 2 of 2
Behaviors of which the respite caregiver should be aware (include bedwetting, tantrums, destructiveness,
emotional issues such as fears and phobias.)
School or daycare and schedule, if applicable:
Any other information the respite caregiver should know: (What level of supervision is required? What is the
best practice to deal with behavioral problems? Is the child allowed to phone his or her biological or foster family
or others? What is the bedtime and daily schedule? What are TV, movie or video restrictions?)
Respite Caregiver: Upon completion of respite care, please return this form to the licensed parent.
Page of 2