Form DCF-Probate-2147 "Medical Questionnaire/Request for Information" - Connecticut

What Is Form DCF-Probate-2147?

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:

  • 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-Probate-2147 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-Probate-2147 "Medical Questionnaire/Request for Information" - Connecticut

922 times
Rate (4.8 / 5) 64 votes
DCF-Probate-2147 Medical Questionnaire/Request for
Information
Revised July 2015
`S
C
D
C
& F
TATE OF
ONNECTICUT
EPARTMENT OF
HILDREN
AMILIES
Medical Questionnaire/Request for Information
HEALTH CARE PROVIDER
DATE
To:
ADDRESS
FAX
DCF WORKER
TELEPHONE
From:
AREA OFFICE
FAX
The Department of Children and Families has a request for a Probate Court study concerning the family of the child listed below. In
accordance with our policies, we are requesting information that would become part of the confidential file. Enclosed is a signed
authorization to release information from your records. We ask that you take a moment to complete this form and return it to us
within two weeks. Thank you for your anticipated assistance in this matter.
Family or Custodial Parent's Name:
Child/Youth:
DOB:
Date of Last Physical:
HT:
WT:
BMI:
How long has the child been a patient in your practice?
years
Has child been seen elsewhere for
NAME OF PROVIDER:
medical care? If so, where?
IF NO, WHAT IS NEEDED?
Is the patient up to date
☐ YES
with immunizations and
☐ NO
well child visits?
☐ YES
IF YES, DATE:
LEVEL:
Has child had lead level
checked?
☐ NO
IF YES, PLEASE EXPLAIN:
Are there any identified
☐ YES
medical or dental
☐ NO
problems?
IF YES, PLEASE EXPLAIN CONCERN AND ANY SPECIALIST REFERRALS MADE:
Are there any
☐ YES
developmental, behavioral,
or mental health
☐ NO
concerns?
If the patient is less than three
If YES, was a referral made to Birth to Three?
☐ YES
☐ NO
☐ YES
(3) years of age would this patient
benefit from a referral of Birth to
☐ NO
☐ Check here if patient already involved with Birth to Three
Three Services?
DCF-Probate-2147 Medical Questionnaire/Request for
Information
Revised July 2015
`S
C
D
C
& F
TATE OF
ONNECTICUT
EPARTMENT OF
HILDREN
AMILIES
Medical Questionnaire/Request for Information
HEALTH CARE PROVIDER
DATE
To:
ADDRESS
FAX
DCF WORKER
TELEPHONE
From:
AREA OFFICE
FAX
The Department of Children and Families has a request for a Probate Court study concerning the family of the child listed below. In
accordance with our policies, we are requesting information that would become part of the confidential file. Enclosed is a signed
authorization to release information from your records. We ask that you take a moment to complete this form and return it to us
within two weeks. Thank you for your anticipated assistance in this matter.
Family or Custodial Parent's Name:
Child/Youth:
DOB:
Date of Last Physical:
HT:
WT:
BMI:
How long has the child been a patient in your practice?
years
Has child been seen elsewhere for
NAME OF PROVIDER:
medical care? If so, where?
IF NO, WHAT IS NEEDED?
Is the patient up to date
☐ YES
with immunizations and
☐ NO
well child visits?
☐ YES
IF YES, DATE:
LEVEL:
Has child had lead level
checked?
☐ NO
IF YES, PLEASE EXPLAIN:
Are there any identified
☐ YES
medical or dental
☐ NO
problems?
IF YES, PLEASE EXPLAIN CONCERN AND ANY SPECIALIST REFERRALS MADE:
Are there any
☐ YES
developmental, behavioral,
or mental health
☐ NO
concerns?
If the patient is less than three
If YES, was a referral made to Birth to Three?
☐ YES
☐ NO
☐ YES
(3) years of age would this patient
benefit from a referral of Birth to
☐ NO
☐ Check here if patient already involved with Birth to Three
Three Services?
IF YES, PLEASE LIST MEDICATION AND WHAT IT IS PRESCRIBED FOR:
☐ YES
Is the child presently on
any medication?
☐ NO
NAME OF SPECIALIST:
DATE OF REFERRAL:
List any specialist referrals made and
dates:
Any missed appointments/ pattern of
missed appointments or other
concerns you would like to discuss
with the DCF worker?
Health Care
Provider's Signature:
Date:
BEST DAYS AND TIMES TO CONTACT:
Days:
☐ Need to speak with Social Worker
Times:
Telephone:
Please attach a copy of:
☐ Immunization records
☐ Last physical exam
Fax to:
Fax #
PLEASE RETURN WITHIN TWO WEEKS
Page of 2