CANS-NY Rating Sheet
Child/Youth’s Name (print): _____________________________________
DOB: __________ Gender: _____ Primary Language: _____________
CANS-NY Completion Date: ___________
Is this the initial CANS-NY (select one):
Yes
No
B2H Waiver Type (select one):
B2H SED
B2H DD
B2H MedF
CANS-NY Administrator (print): ______________________________ Phone #:______________
Agency: ____________________________________________________
Foster Care Status (select one):
In Care
Trial Discharge
D/C to Parent
D/C to Adoption
D/C to Permanent Resource
DOMAINS
Child/Youth Strengths Domain
Note: 0 = Strength
0
1
2
3
0
Family
Spiritual/Religious
Interpersonal
Community Life
Relationship Stability
Talents/Interests
Optimism
Educational
Problem Solving
Vocational
Cultural Identity
Resiliency
01/2012
1
2
3
N/A
1
CANS-NY Rating Sheet
STRENGTHS AND NEEDS DOMAIN FOR PRIMARY CAREGIVER
Instructions for OCFS B2H Providers
The Strengths and Needs Domain for the Primary Caregiver is completed from the perspective of the
permanency plan caregiver. When a child is his/her own medical consenter, this domain is also
completed from the child’s perspective. In addition, where there is more than one family/caregiver (from
separate households) who is involved with the child/youth, but who is not the permanency plan caregiver,
the Strengths and Needs Domain for the Second Caregiver Involvement must be completed. Completing
the Strengths and Needs Domain for the Second Caregiver Involvement allows for determination of
service needs when there is more than one caregiver household who requires B2H Waiver services (e.g.,
when the child is in a pre-adoptive home as the permanency plan, but biological family remains involved).
PERSPECTIVE (select one):
Birth Family
Adoptive
Step-Parent
Youth is Own Medical Consenter
Kinship Foster Family
Non-Kinship Foster Family
Group Home Shift Staff
Other
Strengths Domain
Needs Domain
Note: In this category, 0 = strength
0
1
2
Note: 0 = no evidence of need
0
1
2
3
Supervision
Legal
Care Involvement
Physical
Knowledge
Mental Health
Organization
Substance Use
Natural Supports
Developmental
Residential Stability
Safety
Problem Solving
Acculturation:
Language
3
Cultural Identity
01/2012
2
CANS-NY Rating Sheet
STRENGTHS AND NEEDS DOMAIN FOR SECOND CAREGIVER INVOLVEMENT (SI)
Instructions for OCFS B2H Providers
In addition to the Strengths and Needs Domain for the Primary Caregiver, when there is more than one
family/caregiver (from separate households) who is involved with the child/youth, but who is not the
permanency plan caregiver, the Strengths and Needs Domain for the Second Caregiver Involvement
must be completed. Completing the Strengths and Needs Domain for Second Caregiver Involvement
allows for determination of service needs when there is more than one caregiver household who requires
B2H Waiver services (e.g., when the child is in a pre-adoptive home as the permanency plan, but
biological family remains involved).
PERSPECTIVE (select one):
Birth Family
Adoptive
Step-Parent
Youth is Own Medical Consenter
Kinship Foster Family
Non-Kinship Foster Family
Group Home Shift Staff
Other
Strengths Domain
Needs Domain
Note: In this category, 0 = strength
0
1
2
Note: 0 = no evidence of need
0
1
2
3
Supervision
Legal
Care Involvement
Physical
Knowledge
Mental Health
Organization
Substance Use
Natural Supports
Developmental
Residential Stability
Safety
Problem Solving
Acculturation:
Language
3
Cultural Identity
01/2012
3
CANS-NY Rating Sheet
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

Go to SU Domain
Substance Exposure
Substance Use
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.
01/2012
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CANS-NY Rating Sheet
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.
Child/Youth Risk Behaviors Domain
0
1
2
3
0
Suicide Risk
Psychosis
Self-Injurious Behavior
Impulsive/Hyper
Other Self Harm
Depression
Danger to Others
Anxiety
Sexual Aggression
Oppositional
Delinquent Behavior
Conduct
Exploitation
Anger Control
Fire Setting
Attachment
1
2
3
Runaway
Intentional Misbehavior
Decision Making
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
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.
3
0
Cognitive
Life Threatening
Agitation
Chronicity
Self Stimulation
Diagnostic Complexity
Self Care/Daily Living
Emotional Response
Communication
Impairment in
Functioning
Developmental Delay
Treatment Involvement
Motor
Intensity of Treatment
Sensory
Organizational
Complexity
01/2012
1
2
3
5
CANS-NY Rating Sheet
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
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.
3
0
Sexual Abuse
Severity of Use
Physical Abuse
Duration
Emotional/Verbal Abuse
Peer Anxiety
Medical Trauma
Stage of Recovery
1
2
3
Natural Disaster
Witness to Family
Violence
Witness to Community
Violence
Witness or Victim of
Criminal Activity
Affect Dysregulation
Re-experiencing
Avoidance
Numbing
Dissocation
Somatization
01/2012
6