Form DCF-2107 "Service Agreement - Permanency Placement Services Program (Ppsp)" - Connecticut

What Is Form DCF-2107?

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-2107 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-2107 "Service Agreement - Permanency Placement Services Program (Ppsp)" - Connecticut

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Connecticut Department of Children and Families
SERVICE AGREEMENT - PERMANENCY PLACEMENT SERVICES PROGRAM (PPSP)
DCF-2107
2/17 (Rev.)
Page 1 of 3
Initial
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
DCF Social Worker:
DCF Office:
Please Select DCF Office
Child’s legal status at onset of agreement:
Child’s Permanency Plan at onset of Agreement:
Please Select One
Please Select One
Child’s Placement Type at onset of Agreement
Please Select One
Private Agency Name:
Provider #:
Agency Phone #:
Please Select One
Address: (No. and Street):
City:
State:
Zip:
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.
PPSP Service Category
(Services may only be provided by child placing agencies licensed by the State of Connecticut)
Service Hours
Amount
$ 0.00
1‐ Recruitment and Screening 
$ 0.00
2‐ Home study and Evaluation 
$ 0.00
3‐ Placement Planning 
4 - Post-Placement Supervision
$ 0.00
5-Post Finalization Services (AAP ONLY)
$ 0.00
6-Reunification Services
$ 0.00
7-Supervision After Reunification
$ 0.00
TOTALS
$ 0.00
0
Connecticut Department of Children and Families
SERVICE AGREEMENT - PERMANENCY PLACEMENT SERVICES PROGRAM (PPSP)
DCF-2107
2/17 (Rev.)
Page 1 of 3
Initial
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
DCF Social Worker:
DCF Office:
Please Select DCF Office
Child’s legal status at onset of agreement:
Child’s Permanency Plan at onset of Agreement:
Please Select One
Please Select One
Child’s Placement Type at onset of Agreement
Please Select One
Private Agency Name:
Provider #:
Agency Phone #:
Please Select One
Address: (No. and Street):
City:
State:
Zip:
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.
PPSP Service Category
(Services may only be provided by child placing agencies licensed by the State of Connecticut)
Service Hours
Amount
$ 0.00
1‐ Recruitment and Screening 
$ 0.00
2‐ Home study and Evaluation 
$ 0.00
3‐ Placement Planning 
4 - Post-Placement Supervision
$ 0.00
5-Post Finalization Services (AAP ONLY)
$ 0.00
6-Reunification Services
$ 0.00
7-Supervision After Reunification
$ 0.00
TOTALS
$ 0.00
0
Page 2 of 3
If Reunification, Subsidized Transfer of Guardianship (STOG) or Adoption is the goal, what it the projected date?:
The Private Agency agrees to do the following (list tasks):
Page 3 of 3
The Department of Children and Families agrees to do the following (list tasks):
Start Date:
Expected End Date:
Name of DCF Social Worker:
Signature of DCF Social Worker:
Date:
Social Worker Phone #
Social Worker e-mail address:
Name of DCF Social Work Supervisor:
Signature of DCF Social Work Supervisor:
Date:
Name of DCF Regional Administrator (or Designee):
Signature of DCF Regional Administrator (or Designee):
Date:
Name of Private Agency Social Worker:
Signature of Private Agency Social Worker:
Date:
Private Agency Social Worker Phone #
Private Agency Social Worker e-mail address:
Name of Private Agency Supervisor/Director:
Signature of Private Agency Supervisor/Director:
Date:
PLEASE SEND COPY TO: DCF Office of Children and Youth in Placement (OChYP), 505 Hudson Street, Hartford, CT 06106
Page of 3