CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS) …



Child and Adolescent Needs and Strengths (CANS) Results – Ages 0 to 5Use 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 ?????MENTAL HEALTH SCREEN FORMTEXT ?????CHILD/YOUTH RESULTSModuleScoreTrauma FORMTEXT ????? of FORMTEXT ?????Sexual Abuse FORMTEXT ????? of FORMTEXT ?????Life Functioning FORMTEXT ????? of FORMTEXT ?????Developmental FORMTEXT ????? of FORMTEXT ?????Regulatory FORMTEXT ????? of FORMTEXT ?????Medical FORMTEXT ????? of FORMTEXT ?????Preschool / Child Care FORMTEXT ????? of FORMTEXT ?????Child and Family Cultural Factors FORMTEXT ????? of FORMTEXT ?????Child Behavioral / Emotional Needs FORMTEXT ????? of FORMTEXT ?????Child Risk Factors FORMTEXT ????? of FORMTEXT ?????Child Risk Behaviors FORMTEXT ????? of FORMTEXT ?????Child Strengths FORMTEXT ????? of FORMTEXT ?????TOTAL SCORE FORMTEXT ????? of FORMTEXT ?????CURRENT CAREGIVER RESULTSFull NameScoreLevel of Care FORMTEXT ????? FORMTEXT ????? of FORMTEXT ????? FORMTEXT ?????IDENTIFIED PERMANENT RESOURCE RESULTSFull NameTypeScoreLevel 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 – Parent / Legal GuardianDate SignedSIGNATURE – Parent / Legal GuardianDate SignedSIGNATURE – Current CaregiverDate Signed FORMTEXT ?????Child Welfare Professional Full NameSIGNATURE – Child Welfare Professional Full NameDate 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 ModuleActions 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 ?????TRAUMA0123PRESCHOOL / CHILD CARE0123Sexual Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Preschool / Child Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Emotional Closeness to Perpetrator FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Attendance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Frequency of Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Compatibility FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Duration FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Physical Force FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Achievement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Reaction to Disclosure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Relationships with Teachers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Victim of Sex Trafficking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Relationships with Peers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Neglect FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Emotional Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical Trauma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD AND FAMILY CULTURAL FACTORS0123Natural or Manmade Disaster FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Language FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Witness to Family Violence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cultural Identity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Witness to Community Violence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traditions and Rituals FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Witness / Victim to Criminal Activity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cultural Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adjustment to Trauma0123Knowledge Congruence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Affect Regulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Help Seeking Congruence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Re-experiencing the Trauma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Expression of Distress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Avoidance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Increased Arousal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Numbing Response FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD BEHAVIORAL / EMOTIONAL NEEDS0123Attachment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX LIFE FUNCTIONING0123Failure to Thrive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family - Nuclear FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Depression (Withdrawn) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family - Extended FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxiety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Living Situation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Atypical Behaviors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developmental FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Impulsive / Hyperactive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Cognitive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Oppositional FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Autism Spectrum FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Communication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Self-Care Daily Living Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD RISK FACTORS0123a. Life Threat FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Birth Weight FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Chronicity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pica FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Diagnostic Complexity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Prenatal Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Emotional Response FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Length of Gestation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Impairment in Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Labor and Delivery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Treatment Involvement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Substance Exposure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX g. Intensity of Treatment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Parent / Sibling Problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX h. Organizational Complexity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maternal Availability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Dental FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Daily Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD RISK BEHAVIORS0123Recreation / Play FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-Harm FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Regulatory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aggressive Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX a. Eating FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intentional Misbehavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Elimination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHILD STRENGTHS0123c. Sensory Reactivity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Relationship Permanence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Emotional Control FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family - Nuclear FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Motor FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family - Extended FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Interpersonal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sleep FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adaptability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Persistence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Curiosity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Resiliency 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 ?????CURRENT CAREGIVER0123Supervision 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 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 ................
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