CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS) STANDARD CANS COMPREHENSIVE

Child’s Name: DOB: Gender: Race/Ethnicity:

Caregiver(s): Form Status: Initial Subsequent Annual Discharge
Case Name:
Case Number:
Assessor: Date of Assessment: m m d d y y

CAREGIVER RESOURCES AND NEEDS

LIFE DOMAIN FUNCTIONING 0=no evidence 1=history or suspicion
0=no evidence 1=history or suspicion 2=interferes with functioning; 3=disabling, dangerous; immediate
2=interferes with functioning; 3=disabling, dangerous; immediate or action needed or intensive action needed
action needed intensive action needed
0 1 2 3
0 1 2 3    
Supervision
Family Functioning    
Involvement with Care    
Living Situation    
Knowledge    
Social Functioning    
Organization    
Recreational    
Social Resources    
Developmental/Intellectual1    
Residential Stability    
Job Functioning    
Medical/Physical    
Legal    
Mental Health    
Medical/Physical    
Substance Use    
Sexual Development    
Developmental    
Sleep    
Safety    
School Behavior    
School Attendance     CHILD BEHAVIORAL/EMOTIONAL NEEDS
School Achievement     0=no evidence 1=history or suspicion
Decision-Making     2=interferes with 3=disabling, dangerous; immediate or
functioning; action needed intensive action needed
STRENGTHS DOMAIN 0 1 2 3
0=Centerpiece strength 1=Useful strength Psychosis (Thought Disorder)    
2=Identified strength 3=No evidence Impulsivity/Hyperactivity    
0 1 2 3 Depression    
Family Strengths     Anxiety    
Interpersonal     Oppositional    
Optimism     Conduct    
Educational Setting     Adjustment to Trauma2    
Vocational     Attachment Difficulties    
Talents/Interests     Anger Control    
Spiritual/Religious     Substance Use3    
Community Life    
Relationship Permanence     RISK BEHAVIORS
Resiliency     0=no evidence 1=history or suspicion
Resourcefulness     2=interferes with functioning; 3=disabling, dangerous; immediate
Cultural Identity     action needed or intensive action needed
Natural Supports     0 1 2 3
Suicide Risk    
CULTURAL FACTORS Non-Suicidal Self-Injurious Behavior    
0=no evidence 1=history or suspicion Other Self-Harm (Recklessness)    
2=interferes with functioning; 3=disabling, dangerous; immediate Danger to Others4    
action needed or intensive action needed
Sexual Aggression5    
0 1 2 3    
Runaway6
Language    
Delinquent Behavior7    
Traditions and Rituals    
Fire Setting9    
Cultural Stress    
Intentional Misbehavior    

Page 1 of 3 October 3, 2016

Standard CANS Comprehensive
 1
Developmental Disabilities Module
2
Trauma Module
3
Substance Use Module
4
Violence Module
INDIVIDUAL ASSESSMENT MODULES 5
Sexually Aggressive Behaviors Module
(rate if indicated on prior sheets) 6
Runaway Module
7
Juvenile Justice Module
8
Decision Making Module
9
Fire Setting Module

DEVELOPMENTAL DISABILITIES MODULE

0=no evidence 1=history or suspicion SUBSTANCE USE MODULE
2=interferes with functioning; 3=disabling, dangerous; immediate 0=no evidence 1=history or suspicion
action needed or intensive action needed 2=interferes with functioning; 3=disabling, dangerous; immediate
0 1 2 3 action needed or intensive action needed
Cognitive     0 1 2 3
Communication     Severity of Use    
Developmental     Duration of Use    
Self-Care/Daily Living Skills     Stage of Recovery    
Peer Influences    
TRAUMA MODULE Parental Influences    
No=no evidence of Trauma Yes=Evidence of Trauma Environmental Influences    
No Yes
  VIOLENCE MODULE
Sexual Abuse
0=no evidence 1=history or suspicion
Physical Abuse  
2=interferes with functioning; 3=disabling, dangerous; immediate
Neglect   action needed or intensive action needed
Emotional Abuse   0 1 2 3
Medical Trauma   Historical risk factors:
Natural or Manmade Disaster   History of Physical Abuse    
Witness to Family Violence   History of Violence    
Witness to Community/School Violence   Witness to Domestic Abuse    
Victim/Witness to Criminal Activity   Witness to Environmental Violence    
War/Terrorism Affected   Emotional/Behavioral Risks:
Disruptions in Caregiving/Attachment Losses   Bullying    
Parental Criminal Behavior   Frustration Management    
If the youth has been sexually abused: Hostility    
0 1 2 3 Paranoid Thinking    
Emotional Closeness to Perpetrator     Secondary Gains from Anger    
Frequency of Abuse     Violent Thinking    
Duration     Resiliency Factors:
Force     Aware of Violence Potential    
Reaction to Disclosure     Response to Consequences    
Traumatic Stress Symptoms: Commitment to Self-Control    
0 1 2 3 Treatment Involvement    
Emotional/Physical Dysregulation    
Intrusions/Re-Experiencing    
Hyperarousal    
Traumatic Grief/Separation    
Numbing    
Dissociation    
Avoidance    

Page 2 of 3 October 3, 2016

Standard CANS Comprehensive
 SEXUALLY AGGRESSIVE BEHAVIORS MODULE
0=no evidence 1=history or suspicion 9 - JUVENILE JUSTICE MODULE
2=interferes with functioning; 3=disabling, dangerous; immediate 0=no evidence 1=history or suspicion
action needed or intensive action needed 2=interferes with functioning; 3=disabling, dangerous; immediate
0 1 2 3 action needed or intensive action needed
Relationship     0 1 2 3
Physical Force/Threat     History    
Planning     Seriousness    
Age Differential     Planning    
Type of Sex Act     Community Safety    
Response to Accusation     Peer Influences    
Temporal Consistency     Parental Criminal Behavior    
History of Sexual Abusive Behavior     Environmental Influences    
Severity of Sexual Abuse    
FIRE SETTING MODULE
Prior Treatment    
0=no evidence 1=history or suspicion
RUNAWAY MODULE 2=interferes with functioning; 3=disabling, dangerous; immediate
action needed or intensive action needed
0=no evidence 1=history or suspicion
2=interferes with functioning; 3=disabling, dangerous; immediate 0 1 2 3
action needed or intensive action needed History    
0 1 2 3 Seriousness    
Frequency of Running     Planning    
Consistency of Destination     Use of Accelerants    
Safety of Destination     Intention to Harm    
Involvement in Illegal Acts     Community Safety    
Likelihood of Return on Own     Response to Accusation    
Involvement of Others     Remorse    
Realistic Expectations     Likelihood of Future Fire Setting    
Planning    

Page 3 of 3 October 3, 2016

Standard CANS Comprehensive