CANS Screening Referral Form - CF 802 4/10

Child’s name: Case number P/L:

CANS Screening Referral
Child and Adolescent Needs and Strengths /

Check one: Initial screening referral Annual Rescreen

Child’s name: / Age: / Date of birth:
// / Case no.person letter:
Branch name:
/ Date of referral:
//
Caseworker name: / Phone number:
Ext.:
Supervisor name: / Phone number:
Ext.:

I certify that the above named child is in the legal care or custody of the Department of Human Services (DHS) and I am requesting the CANS screening for the child.

Please attach(if available and applicable) M.H. assessments, prior assessments (CF 0172RN, (i.e., Special Rate (CF 0172A), Personal Care (CF 0172 RN and CF0172A NPC), CANS, psychological evaluations, IEP, IFSP or 504 Plan and a Release of Information (DHS 2099) to each of the
contacts listed.

Location of child:

Foster parent/Relative caregiver name: / Phonenumber: / Cell number:
Address: (Street/City/State/ZIPcode)
Best time to call:

Other contact information:

Identify parties who have specific information about the child’s strengths and needs and who may be contacted for information.

Mother: / Phone number: / Cell number:
Father: / Phone number: / Cell number:
Other previous caretaker: / Phone number: / Cell number:
Current school contact-name of school and teacher: / Phone number: / Cell number:
Former school contact-name of school and teacher (when school
changed due to entry into substitute care): / Phone number: / Cell number:
Mental health provider’s name: / Phone number: / Cell number:
Other: / Phonenumber: / Cell number:

Complete ONLY when requesting rescreening:

A rescreening of the CANS may be considered prior to the annual review when there has been a significant change in the child’s behavior as outlined in OAR 413-020-0230 and a revision of the supervision plan or case plan has not adequately remedied the child’s behavior.

Date of last screen (request should be at least 90 days from the previous screen):

Describe the new behaviors (include description, length of time occurring, settings, who observed/documented the behaviors, level of threat to self or others):

Describe the efforts put in place to address the behaviors and describe the results of the efforts:

Rescreening requested by:

Foster parent/Relative caregiver name: / Phone number:
Ext.:
Child’s caseworker: / Date: / Phone number:
Ext.:
Supervisor: / Date: / Phone number:
Ext.:
DHS central office use only

ApprovedNot approved

Reason:
LOC manager: / Date:

CF 0802 (04/16)

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