Y-US UNIVERSAL REFERRAL FORM

DCF Provider Link Number 57044

Available "Fee-for-Service"*

These services are available for youth in ALL living arrangements
(Fee schedule and minimum hours may vary)

Trauma-Informed Peer Support Services:
New Referral (avg. 4 hours/day)
Re-Referral/Extension
Emergency Daytime Care & Other Services
Project FLY (Forward Looking Youth)
Transportation/Taxi Services ONLY:
Call 951-7268 ext. 105 at least 3 days prior to need and include detailed instructions on DCF Payment Approval Form

* DCF Payment Approval Form required before start of service

DCF CONTRACTED Service

Better Horizons Prevention Program

New Referral (Limited availability)
(DCF worker's referral for biological homes only; non-DCF referrals may include biological, foster, and adoptive homes)
Submit referral directly;
no DCF gatekeeper

Child Information
Child’s LINK ID Number Child’s Name
Gender Male Female DOB (MM/DD/YYYY)
In DCF System Since Has child disrupted from any placements in the past year? Yes No
Typical behaviors / personality & clinical / mental health concerns / safety issues (diagnosis, medications, hospitalizations. If any, please explain)

PLEASE NOTE: We do not administer medications.
DCF Status (Check One)
01 Dual Commitment (neglected/abused/
delinquent)		 04 Committed FWSN 07 Delinquent Parole Services 14 TPR Child
in Placement		 18 Order of Temporary Custody
02 Committed abuse/neglect/
uncared for		 05 Protective Services (CPS) 08 Voluntary Services 15 Adoption (Subsidized) Other (Explain)
03 Committed Delinquent 06 FWSN
non-committed		 12 Non-DCF but Prior Involvement 16 Adoption
(Not Subsidized)
Caregiver Information
Caregiver First Name

Last Name

Issues/concerns in home
Street Address Home Phone (Include Area Code)
Town / City Work Phone (Include Area Code)
ZIP Code Cell Phone (Include Area Code)
Placement
(Check One)		 Biological Home Adoptive Home Guardianship Special Study Home
Relative Foster Home Foster Home Therapeutic Foster Home Pre-Adoptive Home
Other
DCF Office
Hartford Manchester New Britain Other DCF

Non-DCF

Person Making the Referral: (please include all that apply) (Include Area Code)
Social Worker Phone Number
DCF Supervisor Phone Number
Other Phone Number
*Person making referral will be contacted upon receipt
This Form is Being Submitted by: (required information)
First Name

Last Name

Email Address
Please be sure to fill in all relevant fields as missing information will delay start of services.

For all Fee-For-Service referrals, payment approvals must be received before start of services.
Submit by fax at (860) 951-7269.

Back to top

Click here to read our donation and privacy policy information.

"Y-US," "Youth-United for Survival" and "Better Horizons" are all registered servicemarks with the Connecticut Office of the Secretary of State.
Comments? Problems? webmaster@y-us.org | Site design by Melanie Thomson Communications Design