Form DCF-2190 "Therapeutic Child Care Gatekeeper Form" - Connecticut

What Is Form DCF-2190?

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 September 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-2190 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-2190 "Therapeutic Child Care Gatekeeper Form" - Connecticut

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Connecticut Department of Children and Families
THERAPEUTIC CHILD CARE GATEKEEPER FORM
DCF-2190
9/17 (Rev.)
Page 1 of 2
Child’s LAST Name:
Child’s FIRST Name:
Child’s DOB:
Child’s PID#:
LINK Case #:
Child’s Race:
Child’s Ethnicity:
Child’s Gender:
Please Select One
Please Select One
Please Select One
Caregiver LAST Name:
Caregiver FIRST Name:
Caregiver E-mail:
Caregiver Phone #:
Caregiver Address (No. and Street):
City:
State:
Zip:
Caregiver Relationship to Child:
Language(s) spoken in home:
Please Select One
Please Select One (or enter your own)
Child’s DCF Status:
Is Reunification Plan Permanency?
Yes
No
Please Select One
DCF SW LAST Name:
DCF SW FIRST Name:
SW E-mail:
SW Phone #:
DCF SW Supervisor LAST Name:
DCF SW Supervisor FIRST Name:
SWS E-mail:
SWS Phone #:
DCF Office:
Select DCF Office
Are any of the following risk factors known for this child?
ABI / TBI
Adult in home abused alcohol or prescription/street drugs
Experienced separation from primary caregiver
Homelessness/unstable living situations
History of Neglect
Parent involved with SDCF/DDS as a child
History of Physical Abuse
Parent with cognitive limitations or serious behavioral health issues
History of Sexual Abuse
Witness to domestic violence or DV is present in the home
Lead Exposure
Other:
Does Child present with any of the following trauma symptoms?
Aggression toward family, caregivers or peers
Developmentally inappropriate sexual behaviors
Difficulty paying attention/focusing
Disruptive, unsafe, or dangerous behaviors (running away, self-harm, destroys own/other’s property)
Excessive irritability
Doesn’t speak when developmentally appropriate
Hurst animals
Excessive withdrawal from social interaction
imitating traumatic event during play
Prolonged or extreme tantrums/outbursts. Will tantrum/cry until exhausted
Inability to be soothed or comforted
Terrified responses to sights, sounds, etc. that remind child of the trauma
Sleep /Appetite disturbance
Wild eyes, especially when stressed
Unusually high level of anger/excessive temper
Somatic complaints
Anhedonia (lack of pleasure)
Other:
Expand your reason for referral, including current behavior challenges in early care setting and at home. Describe specific behaviors and family
situations:
Connecticut Department of Children and Families
THERAPEUTIC CHILD CARE GATEKEEPER FORM
DCF-2190
9/17 (Rev.)
Page 1 of 2
Child’s LAST Name:
Child’s FIRST Name:
Child’s DOB:
Child’s PID#:
LINK Case #:
Child’s Race:
Child’s Ethnicity:
Child’s Gender:
Please Select One
Please Select One
Please Select One
Caregiver LAST Name:
Caregiver FIRST Name:
Caregiver E-mail:
Caregiver Phone #:
Caregiver Address (No. and Street):
City:
State:
Zip:
Caregiver Relationship to Child:
Language(s) spoken in home:
Please Select One
Please Select One (or enter your own)
Child’s DCF Status:
Is Reunification Plan Permanency?
Yes
No
Please Select One
DCF SW LAST Name:
DCF SW FIRST Name:
SW E-mail:
SW Phone #:
DCF SW Supervisor LAST Name:
DCF SW Supervisor FIRST Name:
SWS E-mail:
SWS Phone #:
DCF Office:
Select DCF Office
Are any of the following risk factors known for this child?
ABI / TBI
Adult in home abused alcohol or prescription/street drugs
Experienced separation from primary caregiver
Homelessness/unstable living situations
History of Neglect
Parent involved with SDCF/DDS as a child
History of Physical Abuse
Parent with cognitive limitations or serious behavioral health issues
History of Sexual Abuse
Witness to domestic violence or DV is present in the home
Lead Exposure
Other:
Does Child present with any of the following trauma symptoms?
Aggression toward family, caregivers or peers
Developmentally inappropriate sexual behaviors
Difficulty paying attention/focusing
Disruptive, unsafe, or dangerous behaviors (running away, self-harm, destroys own/other’s property)
Excessive irritability
Doesn’t speak when developmentally appropriate
Hurst animals
Excessive withdrawal from social interaction
imitating traumatic event during play
Prolonged or extreme tantrums/outbursts. Will tantrum/cry until exhausted
Inability to be soothed or comforted
Terrified responses to sights, sounds, etc. that remind child of the trauma
Sleep /Appetite disturbance
Wild eyes, especially when stressed
Unusually high level of anger/excessive temper
Somatic complaints
Anhedonia (lack of pleasure)
Other:
Expand your reason for referral, including current behavior challenges in early care setting and at home. Describe specific behaviors and family
situations:
Connecticut Department of Children and Families
THERAPEUTIC CHILD CARE GATEKEEPER FORM
DCF-2190
9/17 (Rev.)
Page 2 of 2
Describe why typical classroom does not meet child’s needs:
Is child currently in an early care setting?:
Yes
No.
Is child on any medication(s)?:
Yes
No.
If “Yes”, please list:
Child’s Medical/Diagnostic Information:
Has the child or family received, or is currently receiving. Intervention to address challenging behaviors?:
Birth-to-Three
Yes
No
If “Yes” for 0-3, has Evaluation been complete?
Yes
No
Please select one
Special Ed. Services
Yes
No
Please select one
Yes
No
Child First
Yes
No
Mental Health Services (Adult)
Please select one
Please select one
Yes
No
ECCP
Yes
No
Outpatient Therapeutic Svs.
Please select one
Please select one
Yes
No
EMPS
Yes
No
Prenatal Substance Exposure
Please select one
Please select one
Yes
No
IPV/FAIR
Yes
No
Substance Use Services
Please select one
Please select one
ATTACHMENTS to this referral:
Current Family Case Plan
Current Child Case Plan
MDE
Other:
DISPOSITION:
Referral NOT Accepted (See below)
Accepted into TCC:
Referred to other services:
If Referral is NOT accepted, Please explain why:
SUBMIT TO BRIDGEPORT
SUBMIT TO NEW BRITAIN
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