Form DCF-2095 "Application for Re-entry to Adolescent Services Program" - Connecticut

What Is Form DCF-2095?

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 April 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-2095 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-2095 "Application for Re-entry to Adolescent Services Program" - Connecticut

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DCF-2095
State of Connecticut
04/2015
Page 1 of 4
Department of Children and Families
(Rev.)
APPLICATION FOR RE-ENTRY TO ADOLESCENT SERVICES PROGRAM
Please fill out completely and return to:
DEMOGRAPHIC INFORMATION
Youth’s Name:
Address:
Street
City
State
Zip Code
Phone #:
Social Security #:
D.O.B.
Age:
Sex:
Race:
Name
Phone Number
Medical Provider
Dental Provider
Attorney
DCF INVOLVEMENT
Most Recent DCF Worker or Office:
Phone #:
Reason for Re-Entry Request: Please explain why you are requesting to re-enter DCF services and why you should be
considered for re-entry.
DCF-2095
State of Connecticut
04/2015
Page 1 of 4
Department of Children and Families
(Rev.)
APPLICATION FOR RE-ENTRY TO ADOLESCENT SERVICES PROGRAM
Please fill out completely and return to:
DEMOGRAPHIC INFORMATION
Youth’s Name:
Address:
Street
City
State
Zip Code
Phone #:
Social Security #:
D.O.B.
Age:
Sex:
Race:
Name
Phone Number
Medical Provider
Dental Provider
Attorney
DCF INVOLVEMENT
Most Recent DCF Worker or Office:
Phone #:
Reason for Re-Entry Request: Please explain why you are requesting to re-enter DCF services and why you should be
considered for re-entry.
DCF-2095
01/2015
Page 2 of 4
APPLICATION FOR RE-ENTRY TO ADOLESCENT SERVICES PROGRAM
(Rev.)
EDUCATION
School:
Grade:
School Type:
College
Vocational
High School
☐ Other (Please explain):
Education Plans after Completing High School
Have You Completed a Life Skills Program? ☐ Yes ☐ No If yes, which program?
In the past 12 months have you: (Please check all that apply.)
Attended school regularly
Received passing grades
Been suspended from school
Performed to your potential
Been truant from school
Been expelled from school
Received poor grades
Been disruptive in school
FAMILY/FRIENDS
What family, friends or other adult supports do you have in place?
Name
Telephone Number
Parent/Guardian:
Parent/Guardian:
Spouse:
Sibling:
Sibling:
Sibling:
Sibling:
Adult Support:
Other:
Other:
COMMUNITY INVOLVEMENT
☐ Mentoring
Clubs/Organizations
Volunteer
Participates in Religious Activities
Paid Employment
Other (please specify):
DCF-2095
01/2015
Page 3 of 4
APPLICATION FOR RE-ENTRY TO ADOLESCENT SERVICES PROGRAM
(Rev.)
MEDICAL AND MENTAL HEALTH
☐ Yes
☐ No
Do you have any unmet medical or dental
If yes, please explain:
needs?
☐ Yes
☐No
I agree to a substance use/abuse evaluation.
Signature:
Date:
☐ Yes
☐ No
I agree to a mental health evaluation.
Signature:
Date:
☐ Yes
☐ No
I agree to a physical health evaluation.
Signature:
Date:
Are you in therapy?
Yes
No
If yes, where?
Name of Therapist:
Phone:
Purpose of Therapy:
☐ Yes
☐ No
If no, have you ever been in therapy?
If yes, please detail when, where, and the reason for therapy.
☐ Yes
☐ No
Are you currently on prescription medication?
If yes, please complete.
Medication
Purpose of Medication
☐ Yes
☐ No
Are you pregnant?
If yes, please specify expected delivery date.
If pregnant, where have you been receiving pre-natal care?
☐ Yes
☐ No
Are you a parent?
If yes, please complete.
Child’s Name
Child’s Age
Child Lives With Me
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
DCF-2095
1/03 (New)
Page 4 of 4
APPLICATION FOR RE-ENTRY TO ADOLESCENT SERVICES PROGRAM
LEGAL/COURT INVOLVEMENT
☐ Not Applicable
☐ Currently on Probation
☐ Probation Completed
Court History:
Probation Officer:
Phone:
Attorney:
Phone:
Reason for Court Involvement:
Criminal Charges, if any:
☐ Yes
☐ No
Do you have any pending criminal charges?
If yes, please explain:
WORK EXPERIENCE
☐ Yes
☐ No
Currently Employed?:
If yes, please complete.
Name of Employer:
Hours Worked Weekly:
☐ Yes
☐ No
Previous Employment History:
If yes, list employer(s) and dates.
Dates Employed
Employer
From:
To:
RESIDENCE HISTORY
Please list the last five places you have lived, beginning with the most current residence.
Dates of Placement
Name and Type of Residence
(Family, Friend, DCF Placement, etc.)
From:
To:
I understand that DCF will review this application within the next 30 days to assess whether or not I will be able
to re-enter the DCF Adolescent Services Program. I understand that failure to answer these questions truthfully
may result in delay, further review or denial of the application.
Signature
Date
Page of 4