Form DCF-2106 "Accounting Invoice - Permanency Placement Services Program (Ppsp)" - Connecticut

What Is Form DCF-2106?

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 February 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 fillable version of Form DCF-2106 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-2106 "Accounting Invoice - Permanency Placement Services Program (Ppsp)" - Connecticut

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Department of Children and Families
ACCOUNTING INVOICE - PERMANENCY PLACEMENT SERVICES PROGRAM (PPSP)
DCF-2106
2/17 (Rev.)
Page 1 of 2
FROM: Private Agency Name:
TO: Child’s DCF Social Worker Name:
Please Select One
Private Agency Staff Person’s Name:
DCF Office:
Please Select DCF Office
Provider #:
Agency Phone Number:
Date Invoice Submitted:
Agency Address: (No. and Street):
City:
State:
Zip:
Child’s LAST Name:
Child’s FIRST Name:
LINK #:
Person ID #:
Child’s DOB:
Child’s Race (as noted in LINK):
Child’s Ethnicity (as noted in LINK):
Please Select One
Please Select One
The above-named child has been referred to the above-named private agency for inclusion in the Permanency Placement Services Program
(PPSP). The Department of Children and Families agrees to purchase the PPSP services checked below, for the hours specified and at the
rate of
per service hour. Please note the maximum amount of hours available to a child is 132!
$ 70.63
Note: The dollar amount is the maximum hourly amount to be paid if the private agency completes each service checked.
SERVICES PROVIDED
1-Recruitment and Screening
5-Post Finalization Services (AAP ONLY)
Date
2-Home Study and Evaluation
6-Reunification Services
Number of
Cost for
Service(s)
3-Placement Planning
7-Supervision After Reunification
Hours
Service(s)
Provided
4-Post-Placement Supervision
Please enter a service code number, (#1-7, using the service code keys listed above) Make sure to include a brief
explanation of what activities occurred during the hours billed. See page 2 for more detailed descriptions of coded services
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
TOTALS
$ 0.00
0
FOR DCF OFFICE USE ONLY
Agreement Effective Date:
Anticipated Agreement End Date:
Total amount of this invoice:
$ 0.00
Name of Invoice Reviewer by (SWS):
Date
Invoice Approved by (RA or Designee):
Date
Department of Children and Families
ACCOUNTING INVOICE - PERMANENCY PLACEMENT SERVICES PROGRAM (PPSP)
DCF-2106
2/17 (Rev.)
Page 1 of 2
FROM: Private Agency Name:
TO: Child’s DCF Social Worker Name:
Please Select One
Private Agency Staff Person’s Name:
DCF Office:
Please Select DCF Office
Provider #:
Agency Phone Number:
Date Invoice Submitted:
Agency Address: (No. and Street):
City:
State:
Zip:
Child’s LAST Name:
Child’s FIRST Name:
LINK #:
Person ID #:
Child’s DOB:
Child’s Race (as noted in LINK):
Child’s Ethnicity (as noted in LINK):
Please Select One
Please Select One
The above-named child has been referred to the above-named private agency for inclusion in the Permanency Placement Services Program
(PPSP). The Department of Children and Families agrees to purchase the PPSP services checked below, for the hours specified and at the
rate of
per service hour. Please note the maximum amount of hours available to a child is 132!
$ 70.63
Note: The dollar amount is the maximum hourly amount to be paid if the private agency completes each service checked.
SERVICES PROVIDED
1-Recruitment and Screening
5-Post Finalization Services (AAP ONLY)
Date
2-Home Study and Evaluation
6-Reunification Services
Number of
Cost for
Service(s)
3-Placement Planning
7-Supervision After Reunification
Hours
Service(s)
Provided
4-Post-Placement Supervision
Please enter a service code number, (#1-7, using the service code keys listed above) Make sure to include a brief
explanation of what activities occurred during the hours billed. See page 2 for more detailed descriptions of coded services
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
TOTALS
$ 0.00
0
FOR DCF OFFICE USE ONLY
Agreement Effective Date:
Anticipated Agreement End Date:
Total amount of this invoice:
$ 0.00
Name of Invoice Reviewer by (SWS):
Date
Invoice Approved by (RA or Designee):
Date
Page 2 of 2
BRIEF DESCRITION OF CODES AND PERMANENCY SERVICES
CODE AND SERVICE
BRIEF DESCRIPTIONS, INCLUDING, BUT NOT LIMITED TO…
Consultation and coordination with the OChYP Permanency Resource Exchange and with the
1 - Recruitment and Screening
child’s DCF Social Worker
Development and placement of advertising (describe ads, flyers and written materials)
Development of community contacts (Include names)
Processing of inquiries
Other (describe)
Note: Include names of families recruited.
Background check process
2 - Home Study and Evaluation
Verifying information, e.g., checking references
Office visits for assessment
Home visits for evaluation
Writing the home study
Other (describe)
Note: Include names of families being studied.
Meetings with DCF staff
3 - Placement Planning
Face-to-face meeting with child to get to know child and develop a rapport
Face-to-face meetings with child’s caregivers
Coordinating decision making through meetings of appropriate staff
Face-to-face meetings with the family to help them learn about the child
Face-to-face meetings with the child to help him or her learn about the family
Initial meetings of child and family
Helping family locate community resources
Life Book work
Other (describe)
Individual, family or group counseling
4 - Post-Placement Supervision
Home visits for parenting skills training
Crisis intervention
Supportive face-to-face meetings with child and/or family
Preparing court documents for finalization
Other (describe)
Assist family in the facilitation of relationship and/or communication with birth relatives.
5 - Post-Finalization Services
Face-to-face support to the family and/or child
(AAP ONLY)
Crisis intervention
Training on specific issues
Other (describe)
6 - Reunification Services
Face-to-face meetings with child, foster family, birth family, relatives
Life Book work
Consultation with professionals (Include names or agencies)
Other (describe)
7 - Supervision after Reunification
Face-to-face meetings with child, birth family and relatives
Progress assessments
Arranging for community services
Other (describe)
Page of 2