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
