Child and Adolescent Needs and Strengths Assessment
CANS Type: ______CANS Begin Date: ___/___/_____
CANS Status:______CANS Status Date: ___/___/_____
Last CANS Date: ___/___/_____ CANS Intensity of Services Recommendation: ______
CFTMIntensity of Services Recommendation: ______
Child Name: ______TFACTSID: ______DOB: ___/___/____
Gender: _____ Race:______
Date Taken into Custody: ___/___/_____
Adjudication Date: ___/___/_____Adjudication: ______
Intensity of Services: ______
Placement Type: ______Placement Sub Type: ______
Service Setting: ______Placement Begin Date: ___/___/_____
Location Name: ______Contract Vendor Name: ______
DCS Family Service Worker Assigned: ______
Region: ______County: ______
Created by: ______Agency: ______Agency Location: ______
Created for: ______Agency: ______Agency Location: ______
Assessor Name: ______Agency: ______Agency Location: ______
Team Leader Name: ______Agency: ______Agency Location: ______
COE Reviewer Name: ______Agency: ______Agency Location: ______
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Child’s Name: ______Date of Birth: ______
SAFETY
CHILDRISK BEHAVIORS
0 1 2 3
Suicide Risk
Self Mutilation
Other Self Harm
Danger to Others go to Violence module
Runaway go to Runaway module
Fire Setting go to FS module
Sanction Seeking Beh
Sexually Reactive Beh
Sexual Aggression go to SAB module
Delinquent Behavior go to DB module
(Adj. NOT = Delinquent.)
Substance Use go to SUD module
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Child’s Name: ______Date of Birth: ______
WELL BEING
LIFE DOMAIN FUNCTIONING
0 1 2 3 NA
Social Functioning
Developmental go to DD module
Recreational
Sexuality
Medical
Physical
Sleep
School Attendance
School Behavior
School Achievement
Job Functioning
CHILD STRENGTHS—Individual Assets
0 1 2 3 NA
Interpersonal-Adult
Interpersonal-Peer
Resiliency-Crisis
Resiliency-Long Term
Optimism
Educational
Vocational
Talents/Interests
CHILD BEHAVIORAL/EMOTIONAL NEEDS
0 1 2 3
Psychosis
Impulsivity/Hyperactivity
Depression
Anxiety
Oppositional
Conduct
Trauma Experience(s) go to Trauma module
Attachment
Anger Control
Emotional Control
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Child’s Name: ______Date of Birth: ______
PERMANENCE
LIFE DOMAIN FUNCTIONING
0 1 2 3 NA
Family-Nuclear
Family-Extended
Living Situation
Legal go to YLS tool
(Adj. = Delinquent.)
ACCULTURATION
0 1 2 3
Language
Identity
Ritual
Cultural Stress
CHILD STRENGTHS—Social Assets
0 1 2 3
Family-Nuclear
Family-Extended
Spiritual/Religious
Community Life
Natural Supports
Parental Permanence
Comments:______
______
______
______
______
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Child’s Name: ______Date of Birth: ______
VIOLENCE MODULE
Historical Risk Factors 0123 see attached coding definitions
History of Physical Abuse
History of Violence
Witness to Domestic Violence
Witness to Environmental Violence
Emotional/Behavioral Risks 0123
Bullying
Frustration Management
Hostility
Paranoid Thinking
Secondary Gains from Anger
Violent Thinking
Resiliency Factors 0123
Awareness of Violence Potential
Response to Consequences
Commitment to Self-Control
Treatment Involvement
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Child’s Name: ______Date of Birth: ______
RUNAWAY MODULE
0 1 2 3 see attached coding definitions
Frequency of Running
Consistency of Destination
Safety of Destination
Involvement in Illegal Activities
Likelihood of Return on Own
Duration of Run Episodes
Involvement of Others
Realistic Expectations
Planning
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Child’s Name: ______Date of Birth: ______
FIRE SETTING (FS) MODULE
Approximate date of most recent firesetting behavior (month/year): _____/______
Was the child alone or were other children involved at the time of the incident?
(Circle response) ALONE WITH OTHERS
Rate the youth on the following dimensions based on his/her most recent firesetting behavior and any prior history of similar behaviors.
0 1 2 3see attached coding definitions
Seriousness
History
Planning
Use of Accelerants
Intention to Harm
Community Safety
Response to Accusation
Remorse
Likelihood of Future Fires
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Child’s Name: ______Date of Birth: ______
SEXUALLY ABUSIVE BEHAVIOR (SAB) MODULE
Approximate date of most recent sexually abusive behavior: (month/year): _____/______
How was the child related to his/her known victim(s)? Specify: ______
0 1 2 3see attached coding definitions
Relationship
Physical Force/Threat
Planning
Age Differential
Type of Sex Act
Response to Accusation
Temporal Consistency
History of Sexual Behavior
Severity of Sexual Abuse
Prior Treatment
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Child’s Name: ______Date of Birth: ______
DELINQUENT BEHAVIOR (DB) MODULE
Approximate date of most recent delinquent behavior: (month/year) _____/______
0 1 2 3 see attached coding definitions
Seriousness
History
Planning
Community Safety
Legal Compliance
Peer Influences
Parental Criminal Beh.
Environmental Influences
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Child’s Name: ______Date of Birth: ______
SUBSTANCE USE DISORDER (SUD) MODULE
0 1 2 3see attached coding definitions
Severity of Use
Duration of Use
Stage of Recovery
Peer Influences
Parental Influences
Environment Influences
Does the child have a substance-related diagnosis? (Circle Response) Yes No Undetermined
If YES, specify name of diagnosing agency or staff person: ______
Date of Diagnosis (month/day/year): _____/______/______
Specific Diagnosis: ______
DRUG
/Primary Route of Administration
/ ApproximateAge at First Use /Used regularly (1 time per week or more)?
(circle response) /Used within the past 48 hours?
(circle response)Y N / Y N
Y N / Y N
Y N / Y N
Y N / Y N
Y N / Y N
Y N / Y N
Y N / Y N
Y N / Y N
Y N / Y N
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Child’s Name: ______Date of Birth: ______
DEVELOPMENTAL NEEDS (DD) MODULE
This module is intended to describe any needs that might involve services for Developmental Disabilities including services provided through the Department of Developmental Disabilities.
0 1 2 3
Cognitive
Communication
Developmental
Self Care/Daily Living
Specify IQ: ______(Circle if Unknown) Unknown
Does the child have a developmental diagnosis? (Circle Response) Yes No Undetermined
If YES, specify name of diagnosing agency or staff person: ______
Date of Diagnosis (month/day/year): _____/______/______
Specific Diagnosis: ______
Does the child require any special assistive devices? (Circle response) Yes No Undetermined
If YES, specify name of device and a summary of its use:
______
______
Does the child require any special accommodations for home or school? (Circle response) Yes No Undetermined
If YES, specify a summary of the home or school accommodation:
______
______
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Child’s Name: ______Date of Birth: ______
TRAUMA MODULE
Characteristics of the Traumatic Experience(s): see attached coding definitions
0 1 2 3
Sexual Abuse see below
Physical Abuse
Neglect
Emotional Abuse
Medical Trauma
Natural Disaster
Witness to Family Violence
Witness to Community Violence
Witness/Victim to Criminal Activity
If Sexual Abuse >0, complete the following:
0 1 2 3
Emotional Closeness to Perpetrator
Frequency
Duration
Force
Reaction to Disclosure
Adjustment: see attached coding definitions
0 1 2 3
Reexperiencing
Avoidance
Numbing
Dissociation
Time Before Treatment
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Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.
Distribution: Child’s Case File RDA 2982
CS-0899 5/13