Child and Adolescent Needs and Strengths (Cans) 5-17

DEPARTMENT OF CHILDREN AND FAMILIES

Division of Safety and Permanence

Child and Adolescent Needs and Strengths (CANS) 5-17

Amendment Confirmation of Needs

[TM1]

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

Name – Child / Youth / DOB
[TM2] / [TM3]
Effective Date / Age at Time of Assessment / Name – [TM4]
[TM5] / [TM6] / [TM7]
EMOTIONAL / 0 / 1 / 2 / 3 / PHYSICAL / 0 / 1 / 2 / 3
Adjustment to Trauma / [TM8] / Developmental / [TM9]
Traumatic Grief / Separation / [TM10] / a. Cognitive / [TM11]
Intrusions / [TM12] / b. Autism Spectrum / [TM13]
Attachment / [TM14] / c. Communication / [TM15]
Dissociation / [TM16] / d. Self-Care Daily Living / [TM17]
Eating Disturbance / [TM18] / Medical / [TM19]
Sleep / [TM20] / a. Life Threat / [TM21]
Psychosis / [TM22] / b. Chronicity / [TM23]
Depression / [TM24] / c. Diagnostic Complexity / [TM25]
Anxiety / [TM26] / d. Emotional Response / [TM27]
Somatization / [TM28] / e. Impairment in Functioning / [TM29]
Behavioral Regression / [TM30] / f. Treatment Involvement / [TM31]
Affect Dysregulation / [TM32] / g. Intensity of Treatment / [TM33]
Suicide Risk / [TM34] / h. Organizational Complexity / [TM35]
Self-Injurious Behavior / [TM36] / Physical / [TM37]
Other Self Harm / [TM38] / Dental / [TM39]
Exploited / [TM40] / Daily Functioning / [TM41]
Life Skills / [TM42]
BEHAVIORAL / 0 / 1 / 2 / 3
Living Situation / [TM43]
Social Functioning - Peer / [TM44]
Social Functioning - Adult / [TM45]
Legal / [TM46]
a. Seriousness / [TM47]
b. History / [TM48]
c. Arrests / [TM49]
d. Planning / [TM50]
e. Community Safety / [TM51]
f. Legal Compliance / [TM52]
g. Peer Influences / [TM53]
Sexual Development / [TM54]
Attendance / [TM55]
Behavior / [TM56]
Achievement / [TM57]
Relations with Teacher(s) / [TM58]
Impulsive / Hyperactivity / [TM59]
Oppositional / [TM60]
Conduct / [TM61]
Anger Control / [TM62]
Substance Use / [TM63]
Danger to Others / [TM64]
Sexual Aggression / [TM65]
Delinquent Behavior / [TM66]
Runaway / [TM67]
a. Frequency of Running / [TM68]
b. Consistency of Destination / [TM69]
c. Safety of Destination / [TM70]
d. Involvement in Illegal Activities / [TM71]
e. Likelihood of Return on Own / [TM72]
f. Involvement with Others / [TM73]
g. Realistic Expectations / [TM74]
Intentional Misbehavior / [TM75]
Fire Setting / [TM76]
Bullying / [TM77]

DCF-F-2758-E (N. 01/2012)

[TM1]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.

[TM2]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the First Name, Last Name, and/or MI fields on the Basic tab of the child’s Person Management page.

[TM3]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Birth Date field on the Basic tab of the child’s Person Management page.

[TM4]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be modified on the template. The data cannot be corrected.

[TM5]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Effective Date field on the Amendment page.

[TM6]This field is pre-filled. This field cannot be updated on the template. The data can only be corrected by updating the Birth Date field on the child's Person Management page.

[TM7]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: for the provider identified on the amendment, update the Basic tab of the Person Management page for Parent 1.

[TM8]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM9]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM10]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM11]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM12]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM13]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM14]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM15]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM16]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM17]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM18]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM19]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM20]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM21]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM22]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM23]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM24]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM25]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM26]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM27]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM28]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM29]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM30]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM31]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM32]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM33]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM34]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM35]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM36]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM37]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM38]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM39]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM40]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM41]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM42]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM43]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM44]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM45]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM46]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM47]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM48]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM49]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM50]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM51]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM52]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM53]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM54]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM55]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM56]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM57]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM58]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM59]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM60]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM61]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM62]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM63]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM64]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM65]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM66]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM67]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM68]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM69]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM70]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM71]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM72]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM73]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM74]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM75]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM76]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.

[TM77]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Confirmation of Needs CANS tab on the Amendment page.