Form DCF-2039 "Child Assessment" - Connecticut

What Is Form DCF-2039?

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, 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-2039 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-2039 "Child Assessment" - Connecticut

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Department of Children and Families
CHILD ASSESSMENT
DCF-2039
3/16 (Rev.)
Page 1 of 2
Child’s Last Name:
Child’s First Name:
LINK #:
Person ID #:
Child’s DOB:
Gender:
Child’s Race (as noted in LINK):
Child’s Ethnicity (as noted in LINK):
Please Select One
Please Select One
Date Meeting Held:
DCF Office:
Please Select DCF Office
Legal Status:
Committed, Date:
TPR, Date:
Legal Risk
Please Select One
Child’s Registration/Adoption Plan must be attached it TPR or Legal Risk Adoptive Placement: Attached?:
Yes
No
Long range goal for committed child:
Behavioral / Personality Characteristics (check all that apply):
Please attach the following (most recent) materials:
Active
Friendly
Developmentals
Medical Reports
Adaptable
Hyperactive
DCF-377
Neurologicals
Curious
Reserved
DCF-338 (For Mother)
Psychiatrics
Demonstrative
Shy
DCF-338 (For Father)
Psychologicals
Destructive
Sullen
DCF-416 (if Child is Special Needs)
School Reports
Other:
Easygoing
Withdrawn
Other:
Special Interest(s) of Child (sports/hobbies/current activities:
Peer Relationships (positive and negative):
Education (Attach any school reports in record) See DCF-336, #IV, 24-28:
Present School:
Special Services Received:
Consistency of Attendance:
Relationship with teachers and classmates:
Health History (Attach medical Passport and any evaluations). See DCF-336, III, 22-23, IV, 24-28, V, 29-31. Please note significant disabilities (See DCF-338
or DCF-338B, page 4):
Diagnosis (if any):
Treatment:
Prognosis:
Department of Children and Families
CHILD ASSESSMENT
DCF-2039
3/16 (Rev.)
Page 1 of 2
Child’s Last Name:
Child’s First Name:
LINK #:
Person ID #:
Child’s DOB:
Gender:
Child’s Race (as noted in LINK):
Child’s Ethnicity (as noted in LINK):
Please Select One
Please Select One
Date Meeting Held:
DCF Office:
Please Select DCF Office
Legal Status:
Committed, Date:
TPR, Date:
Legal Risk
Please Select One
Child’s Registration/Adoption Plan must be attached it TPR or Legal Risk Adoptive Placement: Attached?:
Yes
No
Long range goal for committed child:
Behavioral / Personality Characteristics (check all that apply):
Please attach the following (most recent) materials:
Active
Friendly
Developmentals
Medical Reports
Adaptable
Hyperactive
DCF-377
Neurologicals
Curious
Reserved
DCF-338 (For Mother)
Psychiatrics
Demonstrative
Shy
DCF-338 (For Father)
Psychologicals
Destructive
Sullen
DCF-416 (if Child is Special Needs)
School Reports
Other:
Easygoing
Withdrawn
Other:
Special Interest(s) of Child (sports/hobbies/current activities:
Peer Relationships (positive and negative):
Education (Attach any school reports in record) See DCF-336, #IV, 24-28:
Present School:
Special Services Received:
Consistency of Attendance:
Relationship with teachers and classmates:
Health History (Attach medical Passport and any evaluations). See DCF-336, III, 22-23, IV, 24-28, V, 29-31. Please note significant disabilities (See DCF-338
or DCF-338B, page 4):
Diagnosis (if any):
Treatment:
Prognosis:
Page 2 of 2
PLACEMENT HISTORY:
Date
Types
Reason for Removal
Please Select One
Please Select One
Please Select One
Please Select One
Please Select One
Has there been a change in child’s behavioral pattern since child entered care?
Yes
No (If “Yes”, please explain):
If foster parent(s) is/are interested in adopting this child, what is the foster parent(s’) attitude toward any ongoing birth family involvement?:
Are the child’s present caretakers supportive of the plan for child to move?
Yes
No
If ‘Yes” will/can they assist in preparing the child to move?
Yes
No
RECEPTION INTO DCF CARE
Child’s reaction to separation from parent or caretaker (Please explain):
What was child’s understanding about his/her separation from parent or caretaker (Please explain):
SIBLINGS
Last Name
First Name
DOB
Placement
Involved with Referred Child?
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
OTHER SIGNIFICANT PERSONS IN CHILD’S LIFE
Last Name
First Name
DOB
Placement
Involved with Referred Child?
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Yes
No
Please Select One
Last Name of Mother:
First Name of Mother:
Mother’s Last Known Address: (No. & Street):
City:
State:
Zip:
Last Name of Father:
First Name of Father:
Father’s Last Known Address: (No. & Street):
City:
State:
Zip:
Did you remember to attach these documents?:
Attach DCF-337
Attach DCF-338 for Mother
Attach DCF-338 for Father
Name of DCF Social Worker:
Signature of DCF Social Worker:
Date Completed
Name of DCF Social Work Supervisor:
Signature of DCF Social Work Supervisor:
Date Reviewed
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