IM CANS Lifespan Version 1 7 1 18



FORMCHECKBOX Initial FORMCHECKBOX Update FORMCHECKBOX Re-assessmentIllinois Medicaid Comprehensive Assessment of Needs and Strengths (IM+CANS)1. GENERAL INFORMATIONClient First and Last Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????RIN: FORMTEXT ?????Gender: FORMTEXT ?????Referral Source: FORMTEXT ?????Date First Contact: FORMTEXT ?????Phone Number: FORMTEXT ?????Primary Language: FORMTEXT ?????Interpreter Services: FORMCHECKBOX None required FORMCHECKBOX American Sign Language FORMCHECKBOX TDD/TYY FORMCHECKBOX Spoken Language: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????County: FORMTEXT ?????US Citizen: FORMCHECKBOX Yes FORMCHECKBOX No Race: FORMCHECKBOX American Indian/Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Black/African American FORMCHECKBOX Hispanic FORMCHECKBOX Hawaiian Native/Other Pacific Islander FORMCHECKBOX Multi-Race FORMCHECKBOX White FORMCHECKBOX Other: FORMTEXT ?????Ethnicity: FORMCHECKBOX Hispanic FORMCHECKBOX Non-HispanicInsurance Coverage and Company: FORMCHECKBOX N/A FORMTEXT ?????Household Size: FORMTEXT ?????Household Income: FORMTEXT ?????MaritalStatus: FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Domestic Partnership FORMCHECKBOX WidowedGuardianshipStatus: FORMCHECKBOX Own guardian FORMCHECKBOX Biological Parent FORMCHECKBOX Adoptive Parent FORMCHECKBOX Youth in Care FORMCHECKBOX Other court appointed FORMCHECKBOX Other: FORMTEXT ?????Employment Status: FORMCHECKBOX Self-employed FORMCHECKBOX Student FORMCHECKBOX Homemaker FORMCHECKBOX Military FORMCHECKBOX Retired FORMCHECKBOX Unable to work FORMCHECKBOX Employed full-time FORMCHECKBOX Employed part-time FORMCHECKBOX Unemployed LivingArrangement: FORMCHECKBOX Lives alone FORMCHECKBOX Independent Living FORMCHECKBOX Lives with parent(s), relative(s), or guardian(s) FORMCHECKBOX State operated facility (mental health/dev. disability) FORMCHECKBOX Jail or correctional facility FORMCHECKBOX Residential/Institutional Setting (residential, nursing home, shelter) FORMCHECKBOX Community integrated living arrangement (CILA) FORMCHECKBOX Foster Care FORMCHECKBOX Homeless FORMCHECKBOX Other: FORMTEXT ?????Education Level:(last completed) FORMCHECKBOX Never attended FORMCHECKBOX Pre-K/Kindergarten FORMCHECKBOX Grade 1 – 3 FORMCHECKBOX Grade 4 – 5 FORMCHECKBOX Grade 6 – 8 FORMCHECKBOX Grade 9 – 12 FORMCHECKBOX H.S. diploma/GED FORMCHECKBOX Some college FORMCHECKBOX Associate’s degree FORMCHECKBOX Trade/technical training FORMCHECKBOX Professional certificate FORMCHECKBOX Bachelor’s degree FORMCHECKBOX Master’s/Doctoral degreeParent, Guardian, or Significant Other Info.First and Last Name: FORMTEXT ?????Relationship to Client: FORMCHECKBOX Parent FORMCHECKBOX Guardian FORMCHECKBOX Significant Other Phone Number: FORMTEXT ????? Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????County: FORMTEXT ?????Emergency Contact InformationFirst and Last Name: FORMTEXT ?????Relationship to Client: FORMTEXT ?????Phone Number: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????Members ofFamilyConstellationNameAgeRelation to ClientLiving in Home FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoEstablished SupportsAgencyContact NamePhoneEmailPhysician FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????School/Daycare FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Counselor/Therapist FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Child Welfare Worker FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ISC/PAS Agent FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Probation Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Unless otherwise stated, the following categories and action levels are used throughout to score individual CANS items:0 = No evidence/no reason to believe item requires action.1 = Watchful waiting, monitoring or preventive action.2 = Need for Action. Some strategy is needed to address problem/need.3 = Immediate/intensive action. Safety concern; priority for intervention.Please note: Individual CANS items that are not applicable to the entire lifespan have specific age ranges for which the item must be completed indicated in front of the item name. 2. TRAUMA EXPOSURENo = No evidence of any trauma of this type Yes = Client has, or is suspected of having, at least one incident, multiple incidents or chronic, ongoing experience of this type of traumaPOTENTIALLY TRAUMATIC/ADVERSE CHILDHOOD EXPERIENCES (ACEs)ItemNo Yes ItemNo Yes ItemNo Yes Sexual Abuse FORMCHECKBOX FORMCHECKBOX Medical Trauma FORMCHECKBOX FORMCHECKBOX Victim/Witness to Criminal Activity FORMCHECKBOX FORMCHECKBOX Physical Abuse FORMCHECKBOX FORMCHECKBOX Natural or Manmade Disaster FORMCHECKBOX FORMCHECKBOX War/Terrorism Affected FORMCHECKBOX FORMCHECKBOX Neglect FORMCHECKBOX FORMCHECKBOX Witness to Family Violence FORMCHECKBOX FORMCHECKBOX Disruptions in Caregiving/ Attachment Losses FORMCHECKBOX FORMCHECKBOX Emotional Abuse FORMCHECKBOX FORMCHECKBOX Witness to Community/School Violence FORMCHECKBOX FORMCHECKBOX Parental Criminal Behavior FORMCHECKBOX FORMCHECKBOX Supporting Information: Provide additional information on the type of trauma experienced by the client (items rated YES) and the age of occurrence. FORMTEXT ?????3. PRESENTING PROBLEM AND IMPACT ON FUNCTIONING 3a. Presenting Situation and Presenting SymptomsBEHAVIORAL/EMOTIONAL NEEDS n/a 0 1 2 3n/a 0 1 2 3Depression FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Impulsivity/Hyperactivity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxiety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Anger Control/Frustration Tolerance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Eating Disturbance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Substance Use [L – see p. 5] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adjustment to Trauma [A – see below] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Psychosis (Thought Disorder) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Regulatory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Conduct/Antisocial Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Failure to Thrive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16+: Interpersonal Problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Atypical/Repetitive Behaviors [B – p. 3] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Mania FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3-18: Oppositional (Non-compl. w/ auth.) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Somatization FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [A] TRAUMATIC STRESS SYMPTOMS MODULE (To complete when Behavioral/Emotional Needs, Adjustment to Trauma item is rated 1, 2 or 3)Item 0 1 2 3Item 0 1 2 3 Emotional and/or Physical Dysregulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traumatic Grief & Separation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intrusions/Re-experiencing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Numbing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hyperarousal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Dissociation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attachment Difficulties FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Avoidance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3b. Impact of Problems on Client’s FunctioningLIFE FUNCTIONING n/a 0 1 2 3n/a 0 1 2 3Family Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Elimination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Living Situation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-21: School/Preschool/Daycare [C – see p. 3] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Residential Stability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Decision Making FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Legal [K – see p. 4] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Recreation/Play FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Sexual Development FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developmental/Intellectual [B – see p. 3] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16+: Job Functioning/Employment [D – see p. 3] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16+: Parental/Caregiving Role [E – see p. 3] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical/Physical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16+: Independent Living Skills [F – see p. 3] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medication Compliance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16+: Intimate Relationships FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Transportation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Basic Activities of Daily Living FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 1+: Sleep FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Routines FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Motor FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Functional Communication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Sensory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Loneliness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Persistence/Curiosity/Adaptability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [B] DEVELOPMENTAL DISABILITIES MODULE (To complete when Life Functioning Domain, Developmental/Intellectual item or Emotional/Behavioral Needs Domain, Atypical/Repetitive Behaviors item is rated 1, 2 or 3)Itemn/a 0 1 2 3Itemn/a 0 1 2 3Cognitive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Sensory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developmental FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Motor FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-Care/Daily Living Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Regulatory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Autism Spectrum FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [C] SCHOOL/PRESCHOOL/DAYCARE MODULE (To complete when Life Functioning Domain, School/Preschool/Daycare item is rated 1, 2 or 3)Itemn/a 0 1 2 3Itemn/a 0 1 2 3School/Preschool/Daycare Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Relationships with Teachers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX School/Preschool/Daycare Achievement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Preschool/Daycare Quality FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX School/Preschool/Daycare Attendance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX School Needs: FORMCHECKBOX Educational Testing FORMCHECKBOX GED or Credit Recovery FORMCHECKBOX Student Study Team FORMCHECKBOX 504 Plan FORMCHECKBOX IEP FORMCHECKBOX Tutoring[D] VOCATIONAL AND CAREER MODULE (To complete when Life Functioning Domain, Job Functioning/Employment item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3Career Aspirations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Job Performance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Job Time FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Job Relations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Job Attendance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Job Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [E] PARENTING/CAREGIVING MODULE (To complete when Life Functioning Domain, Parental/Caregiving Role item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3Knowledge of Needs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Organization FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Supervision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Marital/Partner Violence In the Home FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement with Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [F] INDEPENDENT ACTIVITIES OF DAILY LIVING MODULE (To complete when Life Functioning Domain, Independent Living Skills item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3Meal Preparation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Money Management FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shopping FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communication Device Use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Housework FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Housing Safety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Supporting Information: Provide additional information regarding presenting situation and symptoms (Emotional/Behavioral items rated 2 and 3). Information on the impact of the presenting situation on the client’s functioning (Life Functioning items rated 2 and 3) should also be included in the narrative. If Modules A-F are completed, please include items rated 2 and 3 in the narrative. FORMTEXT ?????4. SAFETY4a. Risk BehaviorsRISK BEHAVIORSn/a 0 1 2 3n/a 0 1 2 3Victimization/Exploitation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Delinquent/Criminal Behavior [K – see p. 4] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Self-Harm FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Non-Suicidal Self-Inj. Beh. (Self-Mutilation) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3-6: Flight Risk FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Other Self-Harm (Recklessness) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Suicide Risk FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Danger to Others [I – see p. 4] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Intentional Misbehavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Fire Setting [J – see p. 4] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6-21: Runaway [G – see p. 4] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Grave Disability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Sexually Prob. Behavior [H – see p. 4] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Hoarding FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Bullying Others FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [G] RUNAWAY MODULE (To complete when Risk Behaviors Domain, Runaway item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3 Frequency of Running FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Likelihood of Return on Own FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Consistency of Destination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement of Others FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Safety of Destination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Realistic Expectations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement in Illegal Acts FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Planning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [H] – SEXUALLY PROB. BEH. MODULE (To complete when Risk Behaviors Domain, Sexually Problematic Behavior item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3Hypersexuality FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual Aggression [H1 – see below] FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX High Risk Sexual Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexually Reactive Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Masturbation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [H1] SEXUALLY AGGR. BEH. SUB-MODULE (To complete when Sexually Prob. Beh. Module, Sexual Aggression item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3 Relationship FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Power Differential FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical Force/Threat FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Type of Sex Act FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Planning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Response to Accusation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Age Differential FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [I] DANGEROUSNESS MODULE (To complete when Risk Behaviors Domain, Danger to Others item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3 Hostility FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Planning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Paranoid Thinking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Violence History FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Secondary Gains from Anger FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aware of Violence Potential FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Violent Thinking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Response to Consequences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intent FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Commitment to Self-Control FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX [J] FIRE SETTING MODULE (To complete when Risk Behaviors Domain, Fire Setting item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3 Seriousness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Community Safety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Response to Accusation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Planning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Remorse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Use of Accelerants FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Likelihood of Future Fire Setting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intention to Harm FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Supporting Information: Provide additional information regarding the client’s risk behaviors, including aggressive/violent behavior/danger to others (items rated 2 and 3), and the level of impairment (e.g., school suspension, law enforcement involvement, crisis services, hospitalization). FORMTEXT ?????[K] JUSTICE/CRIME MODULE (To complete when Life Functioning Domain, Legal item or Risk Behaviors Domain, Delinq./Criminal Beh. item is rated 1, 2 or 3) Item 0 1 2 3Item 0 1 2 3 Seriousness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Community Safety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Legal Compliance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Arrests FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Peer Influences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Planning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Environmental Influences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Has the client ever been found by a criminal court to be: (check all that apply) Unfit to Stand Trial (UST)? FORMCHECKBOX Yes FORMCHECKBOX No Date(s) of UST finding: FORMTEXT ?????Not Guilty by Reason of Insanity (NGRI)? FORMCHECKBOX Yes FORMCHECKBOX No Date(s) of NGRI finding: FORMTEXT ?????Supporting Information: Provide additional information regarding client’s current and previous legal involvement, including any items rated 2 and 3 in the Justice/Crime Module. Include information on any findings of UST or NGRI, including whether the charges were for a misdemeanor or a felony. FORMTEXT ?????4b. Factors in Current EnvironmentIdentify the factors in the client’s current environment that may create threats to the client’s personal safety (e.g., gang involvement, domestic violence, active abuse, access to weapons, etc.). FORMTEXT ?????5. SUBSTANCE USE HISTORY [L] SUBSTANCE USE MODULE (To complete when Behavioral/Emotional Needs, Substance Use item is rated 1, 2 or 3)Item 0 1 2 3Itemn/a 0 1 2 3 Severity of Use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Peer Influences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Duration of Use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-21: Parental Influences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Stage of Recovery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Recovery Support in Community FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Environmental Influences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Supporting Information: Provide additional information on client’s substance/alcohol abuse (including Substance Use Module items rated 2 and 3, if completed). Specify onset, type – including tobacco and caffeine – frequency, amount and level of impairment (e.g., missing work/school, law enforcement/incarceration, family’s level of concern and attempts to intervene). FORMTEXT ?????Prior Substance Abuse Treatment: FORMCHECKBOX Yes FORMCHECKBOX NoWhenWhereWith WhomReason FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6. PLACEMENT HISTORYDescribe previous and current out-of-home placements for the client including shelters, foster care, group home, nursing home, detention/incarceration, etc. FORMCHECKBOX Client has not had any out of home placements. FORMTEXT ?????7. PSYCHIATRIC INFORMATION7a. Psychiatric ProblemsDescribe significant psychiatric problems, treatments, and outcomes. FORMTEXT ?????7b. General Mental Health HistoryPrior psychological assessment: FORMCHECKBOX Yes FORMCHECKBOX No Date: FORMTEXT ????? IQ: FORMTEXT ?????Prior psychiatric evaluation: FORMCHECKBOX Yes FORMCHECKBOX No Date: FORMTEXT ?????Assessment Needs: FORMCHECKBOX Psychological Testing FORMCHECKBOX Psychiatric EvaluationPrior Outpatient Mental Health Services: FORMCHECKBOX Yes FORMCHECKBOX NoWhenWhereWith WhomReason FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7c. Mental Status: Document clinical observations to support client’s current mental status as noted below. Appearance and Behavior: FORMTEXT ?????Threatening: FORMCHECKBOX Yes FORMCHECKBOX NoMood: FORMCHECKBOX WNL FORMCHECKBOX Depressed FORMCHECKBOX Manic FORMCHECKBOX Anxious FORMCHECKBOX AngrySuicidal: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Expansive FORMCHECKBOX Labile Homicidal: FORMCHECKBOX Yes FORMCHECKBOX NoAffect: FORMCHECKBOX WNL FORMCHECKBOX Sad FORMCHECKBOX Angry FORMCHECKBOX Flat FORMCHECKBOX ConstrictedImpulse Control: FORMCHECKBOX Poor FORMCHECKBOX Good FORMCHECKBOX InappropriateHallucinatory: FORMCHECKBOX Yes FORMCHECKBOX NoInsight: FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorDelusional: FORMCHECKBOX Yes FORMCHECKBOX NoOrientation: FORMCHECKBOX WNL FORMCHECKBOX ImpairedJudgment: FORMCHECKBOX WNL FORMCHECKBOX ImpairedCognition: FORMCHECKBOX WNL FORMCHECKBOX Loose Associations/DisorganizedMemory: FORMCHECKBOX WNL FORMCHECKBOX ImpairedPlease note: WNL = Within Normal Limits8. CLIENT STRENGTHS 0 = Centerpiece Strength 1 = Useful Strength 2 = Identified Strength 3 = Not Yet Identified StrengthCLIENT STRENGTHSn/a 0 1 2 3n/a 0 1 2 3Family Strengths/Support FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Talents and Interests FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Interpersonal/Social Connectedness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Cultural Identity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Natural Supports FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Community Connection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Spiritual/Religious FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Involvement with Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Educational Setting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16+: Vocational FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-21: Relationship Permanence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16+: Job History/Volunteering FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2+: Resiliency FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+: Self-Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Optimism FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Supporting Information: Provide additional information on client’s strengths (items rated 0 and 1) – the aspects of the community and people in the client’s network that provide support, and traits of the client that he/she has used to achieve his/her goals. FORMTEXT ?????9. FAMILY INFORMATION9a. Relevant Family HistoryDescribe precipitating and other significant life events leading to current situation (e.g., divorce, immigration, level of acculturation/assimilation, losses, moves, financial difficulties, etc.). Please include: 1) family history of mental illness, 2) current court involvement (client and family). FORMTEXT ?????9b. Cultural Considerations CULTURAL FACTORS 0 1 2 3 0 1 2 3Language FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cultural Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traditions and Rituals FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Supporting Information: Provide additional information regarding the cultural factors (items rated 2 and 3) that may influence presenting problems (e.g., ethnicity, race, religion, spiritual practice, sexual orientation, transgender, socioeconomic status, living environment, etc.). FORMTEXT ?????10. NEEDS/RESOURCE ASSESSMENT FORMCHECKBOX None. No additional needs/resources identified. FORMCHECKBOX Access to Food FORMCHECKBOX Educational Testing FORMCHECKBOX Mentoring FORMCHECKBOX Financial Assistance FORMCHECKBOX Immigration Assistance FORMCHECKBOX Clothing FORMCHECKBOX Employment FORMCHECKBOX Legal Assistance FORMCHECKBOX Physical Health FORMCHECKBOX Mental Health Service FORMCHECKBOX Shelter FORMCHECKBOX Other (specify): FORMTEXT ?????11. DIAGNOSISDSM-5 Diagnosis:ICD- 10 Diagnosis:PreventiveDiagnostic CodeDSM-5 NameDiagnostic CodeICD-10 NameDiagnosis FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX 12. MENTAL HEALTH ASSESSMENT SUMMARYSummary analysis and conclusion regarding the medical necessity of services. Tie all key information about the client’s mental health needs and diagnosis here. FORMTEXT ?????13. ADDITIONAL CLIENT FUNCTIONING EVALUATIONS RECOMMENDED BY LPHA: FORMCHECKBOX No additional evaluations FORMTEXT ?????14. SUMMARY OF PRIORITIZED CANS NEEDS AND STRENGTHS14a. CANS Actionable Items to Consider for Treatment Planning Background – Trauma ExperiencesBackground – Other NeedsItem: FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX NItem: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX NItem: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX NItem: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Treatment Target NeedsAnticipated Outcome NeedsItem: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Centerpiece/Useful StrengthsStrengths to BuildItem: FORMTEXT ????? FORMCHECKBOX 0 FORMCHECKBOX 1Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 0 FORMCHECKBOX 1Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 0 FORMCHECKBOX 1Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 0 FORMCHECKBOX 1Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Caregiver ResourcesCaregiver NeedsItem: FORMTEXT ????? FORMCHECKBOX 0 FORMCHECKBOX 1Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 0 FORMCHECKBOX 1Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 3Item: FORMTEXT ????? FORMCHECKBOX 0 FORMCHECKBOX 1Item: FORMTEXT ????? FORMCHECKBOX 2 FORMCHECKBOX 315. INDIVIDUAL TREATMENT PLAN15a. Client and Family Vision Statement For Treatment FORMTEXT ?????15b. Client and Family Service Preferences. FORMTEXT ?????16. Treatment Goals and Objectives Treatment Plan Date:___________________All treatment goals and objectives should be stated in client/family language and should relate back to the CANS actionable items identified in box 14a. Goals are specific, observable outcomes related to functioning that result from targeting symptoms and behaviors. Objectives are the specific steps to reach the goal.CANS Item(s): FORMTEXT ????? CLIENT GOAL 1: FORMTEXT ?????Goal Status: FORMCHECKBOX Continue FORMCHECKBOX Discontinue FORMCHECKBOX Completed Date: FORMTEXT ?????Clinical ObjectivesObjective1a. FORMTEXT ?????Objective1b. FORMTEXT ?????Objective1c. FORMTEXT ?????CANS Item(s): FORMTEXT ????? CLIENT GOAL 2: FORMTEXT ????? Goal Status: FORMCHECKBOX Continue FORMCHECKBOX Discontinue FORMCHECKBOX Completed Date: FORMTEXT ?????Clinical ObjectivesObjective2a. FORMTEXT ?????Objective2b. FORMTEXT ?????Objective2c. FORMTEXT ?????CANS Item(s): FORMTEXT ????? CLIENT GOAL 3: FORMTEXT ?????Goal Status: FORMCHECKBOX Continue FORMCHECKBOX Discontinue FORMCHECKBOX Completed Date: FORMTEXT ?????Clinical ObjectivesObjective3a. FORMTEXT ?????Objective3b. FORMTEXT ?????Objective3c. FORMTEXT ?????CANS Item(s): FORMTEXT ????? CLIENT GOAL 4: FORMTEXT ?????Goal Status: FORMCHECKBOX Continue FORMCHECKBOX Discontinue FORMCHECKBOX Completed Date: FORMTEXT ?????Clinical ObjectivesObjective4a. FORMTEXT ?????Objective4b. FORMTEXT ?????Objective4c. FORMTEXT ?????CANS Item(s): FORMTEXT ????? CLIENT GOAL 5: FORMTEXT ?????Goal Status: FORMCHECKBOX Continue FORMCHECKBOX Discontinue FORMCHECKBOX Completed Date: FORMTEXT ?????Clinical ObjectivesObjective5a. FORMTEXT ?????Objective5b. FORMTEXT ?????Objective5c. FORMTEXT ?????Use the service key and mode key below to complete the service section of the treatment plan. For services not listed, please indicate “Other” in the Service Type line and specify the services/interventions to be pursued.SERVICE TYPEKEYSERVICE TYPEKEYSERVICE TYPEKEYSERVICE TYPEKEYTherapy/CounselingTCAssertive Comm. TreatmentACTCase Mgmt -Transition Linkage, AftercareTLAPsych Med AdministrationPMACommunity SupportCSCase Mgmt -Mental HealthMHMental Health Intensive OutpatientIOPsych Med MonitoringPMMCommunity Support TeamCSTCase Mgmt -Client Centered ConsultationCCCPsychosocial RehabilitationPSRPsych Med TrainingPMTSERVICE MODE KEYPLACE OF SERVICE KEYIndividual= IGroup= GFamily= FResidential= ROn-Site= ONOff-Site= OFF17. Services/InterventionsObjective(s)Service TypeModePlace of ServiceAmountFrequencyDurationAgency and Staff Responsible FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????IM+CANS SIGNATURESBy signing this you agree that you have participated in the mental health assessment and treatment planning process and have been given a copy of the completed IM+CANS. You agree that you have had a chance to review the IM+CANS in full, and that the contents have been explained to you in a language that you understand. You understand the risks and benefits of the services outlined in the treatment plan and consent to the services as outlined in this plan. Please document if a youth 12 years of age or older refuses to sign. CLIENT SIGNATURE (required for all clients 12 years of age or older)PARENT/LEGAL GUARDIAN SIGNATUREClient (print name)SignatureDate (mm/dd/yyyy)Parent/Legal Guardian (print name)SignatureDate (mm/dd/yyyy) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????STAFF RESPONSIBLE FOR IM+CANS DEVELOPMENT, REVIEW, AND MODIFICATION SIGNATUREStaff Completing (print name)CredentialsLPHA Authorizer (print name)Credentials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SignatureDate (mm/dd/yyyy)SignatureDate (mm/dd/yyyy) FORMTEXT ????? FORMTEXT ????? ................
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