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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

Child and Adolescent Needs and Strengths (CANS – NY)

Child/Youth's Name(print): _____________________________________

Client ID Number (CIN): ________________________________________
DOB: __________ Gender: _____ Primary Language: ________________
OMH Program: ___________________________________________________

Is this the initial CANS-NY (select one):
Yes
No

CANS-NY Administrator (print): _________________________________
Phone #: ____________________

Agency: ________________________________________________________

CANS-NY Completion Date: __________




DOMAINS


Child/Youth Strengths Domain

Note: 0 = Strength


  0 1 2 3  
Family  
Interpersonal  
Relationship Stability  
Optimism  
Problem Solving  
Cultural Identity  
  0 1 2 3 N/A
Spiritual/Religious  
Community Life  
Talents/Interests  
Educational  
Vocational
Resiliency  



STRENGTHS AND NEEDS DOMAIN FOR PRIMARY CAREGIVER

Instructions for OMH Providers

Check one perspective to identify the primary caregiver and complete this domain. If the youth is his/her own primary caregiver, check and complete for his/her perspective. Please note: Paid staff persons in residential programs such as Community Residences and Residential Treatment Facilities are not considered caregivers.


PERSPECTIVE (check one):

Biological Parent(s) Permanency Plan Family
Adoptive Parent(s) Youth is Her/His Own Caregiver
Kinship Family Foster or Foster Congregate Care


Strengths Domain

Note: In this category, 0 = strength

  0 1 2 3
Supervision
Care Involvement
Knowledge
Organization
Natural Supports
Residential Stability
Problem Solving
Cultural Identity

Needs Domain

Note: 0 = no evidence of need

  0 1 2 3
Legal
Physical
Mental Health
Substance Use
Developmental
Safety
Acculturation: Language



STRENGTHS AND NEEDS DOMAIN FOR SECOND CAREGIVER INVOLVEMENT (SCI)

Instructions for OMH Providers

If there is current or planned involvement with the child/youth from a second perspective that is not the primary caregiver, check that second perspective and complete this domain for that perspective. Be sure you have also completed the proceeding domain for the person identified as the primary caregiver.


PERSPECTIVES:

Biological Parent(s) Permanency Plan Family
Adoptive Parent(s) Youth is Her/His Own Caregiver
Kinship Family Foster or Foster Congregate Care


Strengths Domain

Note: In this category, 0 = strength

  0 1 2 3
Supervision
Care Involvement
Knowledge
Organization
Natural Supports
Residential Stability
Problem Solving
Cultural Identity

Needs Domain

Note: 0 = no evidence of need

  0 1 2 3
Legal
Physical
Mental Health
Substance Use
Developmental
Safety
Acculturation: Language




Child/Youth Life Functioning Domain


 
  0 1 2 3 N/A  
Primary Caregiver    
Family  
Acculturation: Language    
Living Situation    
Sleep    
Sexuality    
Knowledge of Sexuality    
Social Functioning    
Recreational    
Job Functioning  
School Behavior  
School Achievement  
School Attendance  
JJ/Legal    
Developmental Go to DD Domain
Medical Health Go to Med Domain
Behavioral Health Go to BH Domain
Adjustment to Trauma Go to AT Domain
Substance Exposure    
Substance Use Go to SU Domain

Instructions: If child/youth has a rating of “1” or greater in the behavioral health, developmental, or medical health, or substance use dimension, complete the corresponding Behavioral Health, Developmental, Medical Health, or Substance Use Domain. If child/youth has a rating of “1” or higher in the adjustment to trauma dimension, complete the Adjustment to Trauma Domain.





Child/Youth Risk Behaviors Domain

  0 1 2 3
Suicide Risk
Self-Injurious Behavior
Other Self Harm
Danger to Others
Sexual Aggression
Delinquent Behavior
Exploitation
Fire Setting
Runaway
Intentional Misbehavior
Decision Making

Child/Youth Behavioral Health Domain

Complete if the child/youth has a rating of ‘1’ or greater in the Behavioral Health dimension in the Child/Youth Life Functioning Domain. Note: If the child/youth is in an OMH program, this section must be completed.

  0 1 2 3
Psychosis
Impulsive/Hyper
Depression
Anxiety
Oppositional
Conduct
Anger Control
Attachment

Child/Youth Developmental Domain

Complete if the child/youth has a rating of ‘1’ or greater in the developmental dimension in the Child/Youth Life Functioning Domain.

  0 1 2 3
Cognitive
Agitation
Self Stimulation
Self Care/Daily Living
Communication
Developmental Delay
Motor
Sensory

Child/Youth Medical Domain

Complete if the child/youth has a rating ‘1’ or greater in the medical dimension in the Child/Youth Functioning Domain.

  0 1 2 3
Life Threatening
Chronicity
Diagnostic Complexity
Emotional Response
Impairment in Functioning
Treatment Involvement
Intensity of Treatment
Organizational Complexity
Family Stress

Child/Youth Adjustment to Trauma Domain

Complete this module if the child/youth has a rating of ‘1’ or greater in the adjustment to trauma dimension in the Child/Youth Life Functioning Domain.

  0 1 2 3
Sexual Abuse
Physical Abuse
Emotional/Verbal Abuse
Medical Trauma
Natural Disaster
Witness to Family Violence
Witness to Community Violence
Witness or Victim of Criminal Activity
Affect Dysregulation
Re-experiencing
Avoidance
Numbing
Dissociation
Somatization

Child/Youth Substance Abuse Domain

Complete this module if the child/youth has a rating of ‘1’ or greater in the substance use dimension in the Child/Youth Life Functioning Domain.

  0 1 2 3
Severity of Use
Duration
Peer Anxiety
Stage of Recovery

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.