ACTIONABLE ITEMS FOR CHILD



Child and Adolescent Needs and Strengths (CANS) Results – Ages 5 To 21Use of form: The CANS Assessment is required documentation for any child that is placed in out-of-home care. This form provides a breakdown and summary of the child’s CANS score and any actionable items for the child, current caregiver, and permanent resource.Instructions: The CANS Assessment is required to be completed at 30 days of placement and every six months thereafter when the child is with the same provider. The CANS is completed by a child welfare professional trained and certified to complete the CANS in collaboration with the child’s team and current caregiver. Information on this form is pre-filled from the child’s electronic record in eWiSACWIS upon supervisory approval of the CANS Assessment. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].Child/Youth Full NameDate Of Birth (mm/dd/yyyy)Court File Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Effective Date (mm/dd/yyyy)Age at Time of AssessmentAssessment TypeCurrent Caregiver Full Name FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????CHILD/PROVIDER MATCHChild’s Assessed Level of Need (LON): FORMTEXT ?????Provider’s Level of Care (LOC): FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MENTAL HEALTH SCREEN FORMTEXT ?????CHILD/YOUTH RESULTSModuleScoreTrauma FORMTEXT ????? of FORMTEXT ?????Sexual Abuse FORMTEXT ????? of FORMTEXT ?????Life Functioning FORMTEXT ????? of FORMTEXT ?????Developmental FORMTEXT ????? of FORMTEXT ?????Medical FORMTEXT ????? of FORMTEXT ?????Legal FORMTEXT ????? of FORMTEXT ?????School FORMTEXT ????? of FORMTEXT ?????Child and Family Cultural Factors FORMTEXT ????? of FORMTEXT ?????Child / Youth Behavioral / Emotional Needs FORMTEXT ????? of FORMTEXT ?????Child / Youth Risk Behaviors FORMTEXT ????? of FORMTEXT ?????Runaway FORMTEXT ????? of FORMTEXT ?????Child / Youth Strengths FORMTEXT ????? of FORMTEXT ?????TOTAL SCORE FORMTEXT ????? of FORMTEXT ?????CURRENT CAREGIVER RESULTSFull NameScoreLevel of Care FORMTEXT ????? FORMTEXT ????? of FORMTEXT ????? FORMTEXT ?????IDENTIFIED PERMANENT RESOURCE RESULTSNameTypeScoreLevel of Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? of FORMTEXT ????? FORMTEXT ?????CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS)Child/Youth Full NameDate Of Birth (mm/dd/yyyy)Court File Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Effective Date (mm/dd/yyyy)Age at Time of AssessmentAssessment TypeCurrent Caregiver Full Name FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????SIGNATURESSIGNATURE – Child / YouthDate SignedSIGNATURE – Parent / Legal GuardianDate SignedSIGNATURE – Parent / Legal GuardianDate SignedSIGNATURE – Current CaregiverDate Signed FORMTEXT ?????Child Welfare Professional Full NameSIGNATURE – Child Welfare ProfessionalDate Signed FORMTEXT ?????Supervisor Full NameSIGNATURE – SupervisorDate SignedACTIONABLE ITEMS FOR CHILD / YOUTHChild/Youth Full NameDate Of Birth (mm/dd/yyyy)Court File Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Effective Date (mm/dd/yyyy)Age at Time of AssessmentAssessment TypeCurrent Caregiver Full Name FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????Immediate / Intensive Action Needed (3s)Item and ModuleActions to be Taken and by Whom FORMTEXT ????? FORMTEXT ?????Action Needed (2s)Item and ModuleActions to be Taken and by Whom FORMTEXT ????? FORMTEXT ?????Watchful Waiting / Prevention (1s)Item and ModuleActions to be Taken and by Whom FORMTEXT ????? FORMTEXT ?????ACTIONABLE ITEMS FOR CURRENT CAREGIVERChild/Youth Full NameDate Of Birth (mm/dd/yyyy)Court File Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Effective Date (mm/dd/yyyy)Age at Time of AssessmentAssessment TypeCurrent Caregiver Full Name FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????Immediate / Intensive Action Needed (3s)Item and Module Actions to be Taken and by Whom FORMTEXT ????? FORMTEXT ?????Action Needed (2s)Item and ModuleActions to be Taken and by Whom FORMTEXT ????? FORMTEXT ?????ACTIONABLE ITEMS FOR IDENTIFIED PERMANENT RESOURCEChild/Youth Full NameDate Of Birth (mm/dd/yyyy)Court File Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Effective Date (mm/dd/yyyy)Age at Time of AssessmentAssessment TypeCurrent Caregiver Full Name FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????Immediate / Intensive Action Needed (3s)Item and ModuleActions to be Taken and by Whom FORMTEXT ????? FORMTEXT ?????Action Needed (2s)Item and ModuleActions to be Taken and by Whom FORMTEXT ????? FORMTEXT ?????CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS)Child/Youth Full NameDate Of Birth (mm/dd/yyyy)Court File Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Effective Date (mm/dd/yyyy)Age at Time of AssessmentAssessment TypeCurrent Caregiver Full Name FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????TRAUMA0123SCHOOL0123Sexual Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attendance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Emotional Closeness to Perpetrator FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Frequency of Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Achievement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Duration FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Relationships with Teachers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Physical Force FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Reaction to Disclosure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Victim of Sex Trafficking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD AND FAMILY CULTURAL FACTORS0123Neglect FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Language FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Emotional Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cultural Identity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical Trauma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traditions and Rituals FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Natural or Manmade Disaster FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cultural Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Witness to Family Violence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Knowledge Congruence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Witness to Community Violence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Help Seeking Congruence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Witness / Victim to Criminal Activity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Expression of Distress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ADJUSTMENT TO TRAUMA0123Adjustment to Trauma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traumatic Grief / Separation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intrusions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD BEHAVIORAL / EMOTIONAL NEEDS0123Attachment Difficulties FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Psychosis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Dissociation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Impulsive / Hyperactive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Depression FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX LIFE FUNCTIONING0123Anxiety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family - Nuclear FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Oppositional FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family - Extended FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Conduct FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Living Situation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anger Control FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developmental FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Substance Use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Cognitive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Somatization FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Autism Spectrum FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Behavioral Regression FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Communication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Affect Dysregulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Self-Care Daily Living FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Life Threat FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Chronicity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD RISK BEHAVIORS0123c. Diagnostic Complexity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Suicide Risk FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Emotional Response FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Non-Suicidal Self-Injurious Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Impairment in Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other Self Harm FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Treatment Involvement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Exploited FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX g. Intensity of Treatment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Danger to Others FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX h. Organizational Complexity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual Aggression FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Delinquent Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Dental FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Runaway FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Daily Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Frequency of Running FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social Functioning - Peer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Consistency of Destination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX LIFE FUNCTIONING (cont’d)0123CHILD RISK BEHAVIORS (cont’d)0123Social Functioning - Adult FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Safety of Destination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Legal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Involvement in Illegal Activities FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Seriousness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Likelihood of Return on Own FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. History FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Involvement with Others FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Arrests FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX g. Realistic Expectations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Planning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intentional Misbehavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Community Safety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fire Setting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Legal Compliance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bullying FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX g. Peer Influences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX h. Parental Criminal Behavior (Influences) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX i. Environmental Influences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Eating Disturbance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sleep FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual Development FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Life Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Expectant Parent or Parenting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS)Child/Youth Full NameDate Of Birth (mm/dd/yyyy)Court File Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Effective Date (mm/dd/yyyy)Age at Time of AssessmentAssessment TypeCurrent Caregiver Full Name FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????CHILD STRENGTHS0123Relationship Permanence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family - Nuclear FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family - Extended FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Positive Peer Relations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Optimism FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Decision-Making FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Well-Being FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Educational FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Recreational FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Vocational FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Talents / Interests FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Spiritual / Religious FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Community Life FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Youth Involvement With Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Natural Supports FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Resiliency FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Resourcefulness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CURRENT CAREGIVER FORMTEXT ?????0123Supervision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Problem Solving FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement with Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Knowledge FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Empathy with Child FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Organization FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social Resources FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical Health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mental Health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Substance Use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developmental FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cultural Congruence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX IDENTIFIED PERMANENT RESOURCE STRENGTHS AND NEEDS0123 FORMTEXT ?????: FORMTEXT ?????Residential Stability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-Care / Daily Living FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Accessibility to Child Care Services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cultural Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Employment / Educational Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Educational Attainment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Financial Resources FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Community Connection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Legal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Transportation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Supervision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Problem Solving FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement with Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Knowledge FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX IDENTIFIED PERMANENT RESOURCE STRENGTHS AND NEEDS (cont’d)0123Empathy with Child FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Organization FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social Resources FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical Health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mental Health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Substance Use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developmental FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cultural Congruence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ................
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