Form DCF-4100 "Extended Day Treatment Referral Form" - Connecticut

What Is Form DCF-4100?

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 August 1, 2014;
  • 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-4100 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-4100 "Extended Day Treatment Referral Form" - Connecticut

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DCF-4100
Rev. 08/2014
EXTENDED DAY TREATMENT
REFERRAL FORM
(see instructions attached to this form)
Date Received By:
DCF Gatekeeper:
EDT Program:
REFERRAL SOURCE: (Check One)
DCF SW:
Office:
Telephone:
-
-
DCF Supervisor:
Office:
Telephone:
-
-
System of Care Coordinator:
Telephone:
-
-
Community Collaborative:
Telephone:
-
-
Other Name:
Agency:
Telephone:
-
-
REQUESTED EDT PROGRAM:
REASON FOR REFERRAL:
DEMOGRAPHICS
Child’s Name:
Gender:
Female
Male
DOB:
Address:
Telephone:
-
-
City:
State:
Zip Code:
SS#:
Child’s DCF Link Number:
Child’s Primary Insurance:
ID#:
Child’s Secondary Insurance:
ID#:
Primary Language: Parent/Caregiver:
Child:
Secondary Language: Parent/Caregiver:
Child:
Parent/Caregiver’s Name:
Address:
Telephone: Home:
Work:
-
-
-
-
PARENT/CAREGIVER’S RELATIONSHIP TO CHILD
Parent
Foster Parent
Guardian
Relative
Other:
Have the caregivers been informed about the requirements for family involvement?
Yes
No
PERSONS LIVING IN THE HOME WITH CHILD:
NAME
GENDER
DATE OF BIRTH
RELATIONSHIP TO CHILD
ETHNICITY (Check One):
Asian American
Pacific Islander
Hispanic/Latino
Black
White
Native American
Other
1
DCF-4100
Rev. 08/2014
EXTENDED DAY TREATMENT
REFERRAL FORM
(see instructions attached to this form)
Date Received By:
DCF Gatekeeper:
EDT Program:
REFERRAL SOURCE: (Check One)
DCF SW:
Office:
Telephone:
-
-
DCF Supervisor:
Office:
Telephone:
-
-
System of Care Coordinator:
Telephone:
-
-
Community Collaborative:
Telephone:
-
-
Other Name:
Agency:
Telephone:
-
-
REQUESTED EDT PROGRAM:
REASON FOR REFERRAL:
DEMOGRAPHICS
Child’s Name:
Gender:
Female
Male
DOB:
Address:
Telephone:
-
-
City:
State:
Zip Code:
SS#:
Child’s DCF Link Number:
Child’s Primary Insurance:
ID#:
Child’s Secondary Insurance:
ID#:
Primary Language: Parent/Caregiver:
Child:
Secondary Language: Parent/Caregiver:
Child:
Parent/Caregiver’s Name:
Address:
Telephone: Home:
Work:
-
-
-
-
PARENT/CAREGIVER’S RELATIONSHIP TO CHILD
Parent
Foster Parent
Guardian
Relative
Other:
Have the caregivers been informed about the requirements for family involvement?
Yes
No
PERSONS LIVING IN THE HOME WITH CHILD:
NAME
GENDER
DATE OF BIRTH
RELATIONSHIP TO CHILD
ETHNICITY (Check One):
Asian American
Pacific Islander
Hispanic/Latino
Black
White
Native American
Other
1
CHILD’S CURRENT DCF STATUS (Check One):
Dual Commitment
Committed Abuse/Neglect/Uncared
Committed Delinquent
for
Family with Service Needs
Voluntary Services
No Involvement
Protective Services (Intake)
Active (In Home CPS Case)
CHILD’S MENTAL HEALTH/MEDICAL ISSUES
CURRENT DSM-5 DIAGNOSIS
DATE:
BY WHOM:
AXIS I:
AXIS II:
AXIS III:
AXIS IV:
AXIS V:
Current GAF:
Highest in past 6 months:
CURRENT AND PAST BEHAVIORAL HEALTH TREATMENT PROVIDERS/AGENCIES
NAME OF PROVIDER/AGENCY
TYPES OF SERVICES
DATES OF SERVICES
TELEPHONE NUMBER
Child’s Psychiatrist:
Telephone Number:
Child’s Therapist:
Telephone Number:
DESCRIBE ANY CURRENT MEDICAL PROBLEMS:
Does the child take any medications?
Yes
No
Unknown (Meds for physical or behavioral health reasons)
If yes, please list the medications, if known.
Child’s Pediatrician:
Telephone Number:
OTHER AGENCIES/PROGRAMS INVOLVED WITH CHILD AND SERVICES PROVIDED:
COLLATERAL CONTACTS
Name of School:
Town:
Contact Person:
Telephone Number:
Special Education:
Yes
No
Full Scale IQ (If Known):
Probation/Parole Officer:
Yes
No
Contact Person:
Telephone Number:
TRAUMA HISTORY
HAS THE CHILD BEEN EXPOSED TO ANY OF THE FOLLOWING TRAUMATIC EXPERIENCES? (CHECK ALL THAT APPLY)
Physical Abuse:
Community Violence or Victimization:
Sexual Abuse:
Significant Loss
(Attachment Disruptions/Multiple Placements)
Domestic Violence:
Unknown:
2
PRESENTING CONCERNS
Please indicate behaviors that the child demonstrates on the chart below. If necessary, please elaborate or add additional
concerns on a separate sheet.
SYMPTOMS
CURRENT HISTORY
EXPLANATION OF CHECKED ITEMS
Self-injurious
Aggressive Towards Others
Destroying Property
Psychotic Symptoms
Suicidal Ideation
Homicidal Ideation
Sexualized Behaviors
Stealing
Lying
Temper Tantrums
Depression
Anxiety
Running Away
Truancy
Substance Abuse
Cognitive Limitations
Developmental Delays
Bedwetting/Soiling
Other
PLEASE DESCRIBE CHILD’S STRENGTHS (Interpersonal, Community Interests, Other)
DCF SOCIAL WORKER OR SYSTEM OF CARE COORDINATOR
If available at or prior to the intake interview, please provide past
treatment records, reports, and evaluations.
Signature of Referring Source
Date:
Signature of DCF Liaison/Gatekeeper
Date:
(For DCF Referrals)
3
Extended Day Treatment
Referral Form
DCF-4100
Instructions
The Extended Day Treatment (EDT) referral form (DCF-4100), was developed by the EDT Practice
Standards Committee is to be used by all professionals who wish to make a referral to any of the
state’s contracted programs. This includes DCF staff, System of Care Coordinators, school
personnel, hospital staff, treatment providers, residential staff and others. (Parents, guardians or
relatives who are making direct referrals are not expected to use this form.) The form will be readily
available within the communities and may be obtained from the respective EDT providers. The form
may be completed electronically and e-mailed to the provider or the form may be completed
manually and mailed or hand-delivered to the program site.
1. Date Received By
a) For DCF-involved cases, the DCF Gatekeeper will record the date that the
completed referral form was received from the Social Worker or
Supervisor.
b) For all referrals, the EDT provider will record the date of receipt of the referral form.
2. Referral Source
Check the appropriate box to designate the referring agent.
Provide the name, office or agency, and telephone number of the referring agent.
3. Requested EDT Program
Identify the name of the EDT program.
4. Reason for Referral
Briefly explain why the child needs an intermediate level of care.
5. Demographics
Complete each item.
6. Parent/Caregiver’s Relationship to Child
Check the appropriate box. If other, please specify the nature of the relationship.
7. Have the Caregivers been Informed about the Requirements for Family Involvement?
Answer yes or no, as applicable.
Although the referring agent may not be aware of the detailed requirements, it is important to
inform families immediately that their participation in treatment planning and service delivery
is expected and an integral part of the program.
8. Persons Living in the Home with Child
List each person who resides in the home and specify gender, date of birth and relationship
to child.
9. Ethnicity
Check the appropriate box.
10. Child’s Current DCF Status
Check the appropriate box.
4
11. Child’s Mental Health/Medical Issues
Indicate the date of the most current diagnosis, and the treating provider.
Complete Axes 1 through V.
12. Current/Past Behavioral Health Treatment Providers/Agencies
List each provider and agency, types of services, dates of services, and telephone numbers.
Provide the names and telephone numbers for the child’s psychiatrist and therapist, as
applicable.
13. Describe any Current Medical Problems
Briefly describe any current physical health issues.
Check whether or not the child takes any type of medication for physical or psychiatric health
issues. If yes, list all medications.
Provide the name and telephone number of the child’s pediatrician.
14. Other Agencies/Programs Involved with Child and Services Provided
List any other involved agencies or programs and identify the services provided.
15. Collateral Contacts
Answer each item. Identify contacts, as applicable. Specify IQ, if known.
16. Trauma History
Check all the boxes that are applicable.
17. Presenting Concerns
Check the appropriate boxes that describe symptoms or behaviors, indicating current or past,
or both, and explain the nature of these concerns, as necessary.
18. Please Describe Child’s Strengths
Identify the child’s assets such as talents, interests, interpersonal skills, etc.
19. Signature of Referring Source
Referring agent must sign and date the form.
20. Signature of DCF Liaison/Gatekeeper
For DCF-involved cases, the DCF Liaison/Gatekeeper must sign and date the form.
21. DCF Social Worker or System of Care Coordinator
If available at or prior to intake, please provide any pertinent treatment records, reports and
evaluations.
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