Form DCF-472 "Family Assessment - for Use With Foster and Adoptive Homes" - Connecticut

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What Is Form DCF-472?

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 July 1, 2018;
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-472 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

Download Form DCF-472 "Family Assessment - for Use With Foster and Adoptive Homes" - Connecticut

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Connecticut Department of Children and Families

FAMILY ASSESSMENT - FOR USE WITH FOSTER AND ADOPTIVE HOMES

DCF-472

7/18 (Rev.)

Page 1 of 26

Family Name:

Worker’s Name:

Approval Date (for private agency use)

DCF Office:

Select DCF Office

Resource Family for:

Adoption

Foster Care

LINK#

APPLICANTS FAMILY SUMMARY INFORMATION

Applicant 1

Applicant 2

Last Name:

First Name:

Last Name:

First Name:

DOB:

Gender/Identity/Expression:

DOB:

Gender/Identity/Expression:

Select One or Enter your own

Home Phone

Work Phone:

Cell Phone:

Home Phone

Work Phone:

Cell Phone:

E-mail:

E-Mail:

Race:

Ethnicity:

Race:

Ethnicity:

Select One

Language(s):

Religion, if any:

Language(s):

Religion, if any:

Select one, or enter your own

Address: (No. and Street):

City:

State:

Zip:

Mailing Address (If different from above):

City:

State:

Zip:

Protective Services

Check

Date

Protective Services

Check

Date

Attached

Pending

Attached

Pending

History Checks

completed

History Checks

completed

LINK Case Search

LINK CMS Search

LINK Perpetrator Search

LINK Person Search

LINK Provider Search

Criminal Checks:

COLLECT

DMV

Fingerprints

Local Police

State Police

Connecticut Department of Children and Families

FAMILY ASSESSMENT - FOR USE WITH FOSTER AND ADOPTIVE HOMES

DCF-472

7/18 (Rev.)

Page 1 of 26

Family Name:

Worker’s Name:

Approval Date (for private agency use)

DCF Office:

Select DCF Office

Resource Family for:

Adoption

Foster Care

LINK#

APPLICANTS FAMILY SUMMARY INFORMATION

Applicant 1

Applicant 2

Last Name:

First Name:

Last Name:

First Name:

DOB:

Gender/Identity/Expression:

DOB:

Gender/Identity/Expression:

Select One or Enter your own

Home Phone

Work Phone:

Cell Phone:

Home Phone

Work Phone:

Cell Phone:

E-mail:

E-Mail:

Race:

Ethnicity:

Race:

Ethnicity:

Select One

Language(s):

Religion, if any:

Language(s):

Religion, if any:

Select one, or enter your own

Address: (No. and Street):

City:

State:

Zip:

Mailing Address (If different from above):

City:

State:

Zip:

Protective Services

Check

Date

Protective Services

Check

Date

Attached

Pending

Attached

Pending

History Checks

completed

History Checks

completed

LINK Case Search

LINK CMS Search

LINK Perpetrator Search

LINK Person Search

LINK Provider Search

Criminal Checks:

COLLECT

DMV

Fingerprints

Local Police

State Police

DCF-472

FAMILY ASSESSMENT - FOR USE WITH FOSTER AND ADOPTIVE HOMES

Page 2 of 26

OTHER ADULTS IN THE HOUSEHOLD

Adult 1

Adult 2

Last Name:

First Name:

Last Name:

First Name:

DOB:

Gender/Identity/Expression:

DOB:

Gender/Identity/Expression:

Select One or Enter your own

Home Phone

Work Phone:

Cell Phone:

Home Phone

Work Phone:

Cell Phone:

E-mail:

E-Mail:

Race:

Ethnicity:

Race:

Ethnicity:

Select One

Language(s):

Religion, if any

Language(s):

Religion, if any

Select one, or enter your own

Relationship to Applicant:

Select One or enter your own

Address: (No. and Street):

City

State

Zip

Mailing Address (If different from above):

City

State

Zip

Protective Services

Check

Date

Protective Services

Check

Date

Attached

Pending

Attached

Pending

History Checks

completed

History Checks

completed

LINK Case Search

LINK CMS Search

LINK Perpetrator Search

LINK Person Search

LINK Provider Search

Criminal Checks:

COLLECT

DMV

Fingerprints

Local Police

State Police

CHILDREN IN HOME

Last Name:

First Name:

DOB:

Gender:

Race:

Ethnicity:

Biological

Adopted

Guardianship

Select One

Select One or Enter your own

Fam. Arrange.

Last Name:

First Name:

DOB:

Gender:

Race:

Ethnicity:

Biological

Adopted

Select One

Guardianship

Select One

Select One or Enter your own

Fam. Arrange

Last Name:

First Name:

DOB:

Gender:

Biological

Race:

Ethnicity:

Adopted

Guardianship

Select One

Select One or Enter your own

Fam. Arrange

Last Name:

First Name:

DOB:

Gender:

Biological

Race:

Ethnicity:

Adopted

Guardianship

Select One

Select One or Enter your own

Fam. Arrange

Last Name:

First Name:

DOB:

Gender:

Biological

Race:

Ethnicity:

Adopted

Guardianship

Select One

Select One or Enter your own

Fam. Arrange

Last Name:

First Name:

DOB:

Gender:

Biological

Race:

Ethnicity:

Adopted

Guardianship

Select One

Select One or Enter your own

Fam. Arrange

Please attach a separate page(s) for additional children

DCF-472

FAMILY ASSESSMENT - FOR USE WITH FOSTER AND ADOPTIVE HOMES

Page 3 of 26

ADDITIONAL REQUIRED HOME STUDY ASSESSMENT INFORMATION:

List of Contact Dates during Assessment: (Include dates of group study sessions, individual and joint interviews, home visits and collateral contacts.)

Dates:

Person(s) contacted:

REFERENCES CONTACTED:

Name

:Relationship / Status

MOTIVATION Give the stated and assessed motivation to provide foster care or to adopt.

Study Worker’s Assessment: Include observations, review of group participation, interviews and attach written materials as needed:

DCF-472

FAMILY ASSESSMENT - FOR USE WITH FOSTER AND ADOPTIVE HOMES

Page 4 of 26

HISTORY – APPLICANT 1

Childhood: Applicant relationships, sibling relationships, impression of his or her childhood. Any history of sexual abuse, domestic violence, substance use in

family members? How he or she dealt with any prior domestic violence or substance use? What, if any, effect has domestic violence or substance use had on his

or her familial relationships?

Applicant #1 History of Serious Relationships:

DCF-472

FAMILY ASSESSMENT - FOR USE WITH FOSTER AND ADOPTIVE HOMES

Page 5 of 26

Applicant #1 History of any Significant Losses: Include strengths and any significant issues. Identify personal losses and how they were dealt with.

Applicant #1 Type of Loss

Age Occurred

Expected or Not

Select One, if applicable