Form DCF-416 "Certification of Special Needs Status" - Connecticut

What Is Form DCF-416?

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 January 1, 2019;
  • 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-416 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-416 "Certification of Special Needs Status" - Connecticut

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Department of Children and Families
CERTIFICATION OF SPECIAL NEEDS STATUS
DCF-416
1/19 (Rev.)
Page 1 of 1
Child’s LAST Name:
Child’s FIRST Name:
DOB:
Gender:
Date of Commitment
Please Select One
Name of Private Agency (If Applicable)
Race:
Ethnicity:
Please Select One
Please Select One
Address: (No. and Street)
City
State
Zip
Check All that Apply and Explain Below (please attach documentation where indicated):
Physical disability (or high risk of such disability) which presents a barrier to adoption. A written diagnosis and recommendation for treatment must be
made by a licensed physician.
Mental disability (or high risk of such disability) which presents a barrier to adoption. A written diagnosis and recommendation for treatment must be
made by a licensed psychiatrist or psychologist.
Serious emotional maladjustment (or high risk of such maladjustment) as indicated by a written diagnosis made by a licensed psychiatrist or
psychologist. The written statement must include recommendation for treatment and prognosis.
Age, when considered with other factors in the child’s functioning and circumstances, presents a barrier to adoption.
Racial or ethnic factors, when considered with other factors in the child’s functioning and circumstances, that present a barrier to adoption.
Member of a sibling group which should be placed together.
The child has established significant emotional ties with prospective adoptive parents.
Explanation:
Recommended by LAST :Name:
FIRST Name:
Signature:
Date
Approved by PS LAST Name:
PS FIRST Name:
PS Signature:
Date
Department of Children and Families
CERTIFICATION OF SPECIAL NEEDS STATUS
DCF-416
1/19 (Rev.)
Page 1 of 1
Child’s LAST Name:
Child’s FIRST Name:
DOB:
Gender:
Date of Commitment
Please Select One
Name of Private Agency (If Applicable)
Race:
Ethnicity:
Please Select One
Please Select One
Address: (No. and Street)
City
State
Zip
Check All that Apply and Explain Below (please attach documentation where indicated):
Physical disability (or high risk of such disability) which presents a barrier to adoption. A written diagnosis and recommendation for treatment must be
made by a licensed physician.
Mental disability (or high risk of such disability) which presents a barrier to adoption. A written diagnosis and recommendation for treatment must be
made by a licensed psychiatrist or psychologist.
Serious emotional maladjustment (or high risk of such maladjustment) as indicated by a written diagnosis made by a licensed psychiatrist or
psychologist. The written statement must include recommendation for treatment and prognosis.
Age, when considered with other factors in the child’s functioning and circumstances, presents a barrier to adoption.
Racial or ethnic factors, when considered with other factors in the child’s functioning and circumstances, that present a barrier to adoption.
Member of a sibling group which should be placed together.
The child has established significant emotional ties with prospective adoptive parents.
Explanation:
Recommended by LAST :Name:
FIRST Name:
Signature:
Date
Approved by PS LAST Name:
PS FIRST Name:
PS Signature:
Date