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

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.

ADVERTISEMENT
ADVERTISEMENT

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

1282 times
Rate (4.6 / 5) 90 votes
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:
M.
Last Name:
First Name:
M.
DOB:
Gender/Identity/Expression:
DOB:
Gender/Identity/Expression:
Select One or Enter your own
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
Select One
Select One
Select One
Language(s):
Religion, if any:
Language(s):
Religion, if any:
Select one, or enter your own
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
completed
History Checks
completed
completed
LINK Case Search
LINK Case Search
LINK CMS Search
LINK CMS Search
LINK Perpetrator Search
LINK Perpetrator Search
LINK Person Search
LINK Person Search
LINK Provider Search
LINK Provider Search
Criminal Checks:
Criminal Checks:
COLLECT
COLLECT
DMV
DMV
Fingerprints
Fingerprints
Local Police
Local Police
State 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:
M.
Last Name:
First Name:
M.
DOB:
Gender/Identity/Expression:
DOB:
Gender/Identity/Expression:
Select One or Enter your own
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
Select One
Select One
Select One
Language(s):
Religion, if any:
Language(s):
Religion, if any:
Select one, or enter your own
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
completed
History Checks
completed
completed
LINK Case Search
LINK Case Search
LINK CMS Search
LINK CMS Search
LINK Perpetrator Search
LINK Perpetrator Search
LINK Person Search
LINK Person Search
LINK Provider Search
LINK Provider Search
Criminal Checks:
Criminal Checks:
COLLECT
COLLECT
DMV
DMV
Fingerprints
Fingerprints
Local Police
Local Police
State 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:
M.
Last Name:
First Name:
M.
DOB:
Gender/Identity/Expression:
DOB:
Gender/Identity/Expression:
Select One or Enter your own
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
Select One
Select One
Select One
Language(s):
Religion, if any
Language(s):
Religion, if any
Select one, or enter your own
Select one, or enter your own
Relationship to Applicant:
Relationship to Applicant:
Select One or enter your own
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
completed
History Checks
completed
completed
LINK Case Search
LINK Case Search
LINK CMS Search
LINK CMS Search
LINK Perpetrator Search
LINK Perpetrator Search
LINK Person Search
LINK Person Search
LINK Provider Search
LINK Provider Search
Criminal Checks:
Criminal Checks:
COLLECT
COLLECT
DMV
DMV
Fingerprints
Fingerprints
Local Police
Local Police
State Police
State Police
CHILDREN IN HOME
Last Name:
First Name:
M:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Guardianship
Select One
Select One
Select One or Enter your own
Fam. Arrange.
Last Name:
First Name:
M:
DOB:
Gender:
Race:
Ethnicity:
Biological
Adopted
Select One
Guardianship
Select One
Select One or Enter your own
Fam. Arrange
Last Name:
First Name:
M:
DOB:
Gender:
Biological
Race:
Ethnicity:
Adopted
Guardianship
Select One
Select One
Select One or Enter your own
Fam. Arrange
Last Name:
First Name:
M:
DOB:
Gender:
Biological
Race:
Ethnicity:
Adopted
Guardianship
Select One
Select One
Select One or Enter your own
Fam. Arrange
Last Name:
First Name:
M:
DOB:
Gender:
Biological
Race:
Ethnicity:
Adopted
Guardianship
Select One
Select One
Select One or Enter your own
Fam. Arrange
Last Name:
First Name:
M:
DOB:
Gender:
Biological
Race:
Ethnicity:
Adopted
Guardianship
Select One
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
Select One, if applicable
Select One, if applicable
Select One, if applicable