CANS-NY Score Sheet
AGES 6 to 21
VERSION: November 2, 2016
CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS) 6 to 21
Child Name:
Check one:
Initial CANS
Child’s Current Living
Setting: (Check only one)
Caregiver Name
Child CIN:
Child Sex:
Follow-up CANS Child Age (at time of CANS):
Birth or Relative Home
Kinship Foster Home
Congregate Care
Adoptive Home
Non-Kinship Foster Home
On Own
Caregiver Relationship to Child (Check only one per caregiver)
Kinship
Non-kin
Other
Other
Foster
Foster
NonMother
Father
Relative
Parent
Parent
relative
Caregiver 1.
Caregiver 2.
Caregiver 3.
Caregiver 4.
Check if child has no identified Caregiver
Care Manager:
CANS Completion Date:
NEEDS RATING INTENSITY/ACTION LEVEL
“0” indicates no evidence. No need for action.
“1” indicates watchful waiting/prevention. This
need should be monitored, or efforts to
prevent it from returning or getting worse
should be initiated.
“2” indicates action. An intervention of some
type is required because the need is
interfering in some notable way with the
individual’s, family’s or community’s
functioning.
“3” indicates immediate/ intensive action. This
need is either dangerous or disabling.
m
m
d
d
y
y
STRENGTHS RATING INTENSITY/ACTION LEVEL
“0” is centerpiece strength. It indicates a strength that is so
powerful and important to the person that it can be used
as the focal point for a strength-based planning process.
“1” is a useful strength. While by no means as powerful as
centerpiece strength, this level indicates a strength that
still could be useful for strength-based planning. It is real
and ready to be included in the plan.
“2” is an identified strength. This is a strength identified as
having the potential to develop but is not useful at the
present time. Examples are interest in music or a hobby
that is not being developed, or a vocational preference
that is not being pursued. Strength-building activities
would be indicated.
“3” indicates no strength is identified. This level indicates that
there is no known strength. Strength identification and
building are indicated.
UNLESS OTHERWISE NOTED, RATINGS REFER TO CONDITIONS WITHIN THE LAST 30 DAYS.
CANS-NY 6 to 21 Score Sheet
Page |1
CANS-NY Score Sheet
A.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
AGES 6 to 21
VERSION: November 2, 2016
CAREGIVER STRENGTHS & NEEDS
If child has more than two caregivers, copy this page to rate additional caregivers
Caregiver 1
Caregiver 2
0
1
2
3
NA
0
1
2
3
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Physical Health
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Developmental
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Mental Health
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Substance Use
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Partner Relationship
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Caregiver Adjustment to Trauma
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Legal
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Acculturation/Language
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Culture Stress
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Self-Care/Daily-Living
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Organization
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Supervision
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Resourcefulness
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Decision-Making
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Parenting Stress
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Housing Safety
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Residential Stability
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Financial Resources
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Safety from Others
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Informal Supports
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Cultural Differences within a Family
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Transportation of Child
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Knowledge of Condition
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Care/Treatment Involvement
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Knowledge Congruence
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Family Relationship to the System
CANS-NY 6 to 21 Score Sheet
P.1
NA

Page |2
CANS-NY Score Sheet
B.
27
28
29
30
31
32
33
34
35
36
37
38
39
C.
40
41
42
43
44
45
46
47
48
D.
49
50
51
52
53
AGES 6 to 21
CHILD STRENGTHS
Family of Origin
Foster Family
Social Relationships
With Peers
Social Relationships
With Adults
Relationship Stability
Optimism
Resourcefulness
Adaptability
Persistence
Resilience/Internal
Strengths
Talents/Interests
Cultural Identity
Spiritual/
Religious
0
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1
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2
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3
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CHILD NEEDS & FUNCTIONING
0

Living Situation
Acculturation/

Language

Peer Interactions
Decision
Making/Judgment

Sleep

Physical Limitations

Dental Needs

Recreational
Juvenile Justice/

Legal
SCHOOL/ACADEMIC FUNCTION
0
1
Educational
 
Partnership
 
School Behavior
 
School Achievement
 
School Attendance
 
Learning Ability
P.7
NA

E.
54
55
56
57
58
59
60
61
62
63
64
65
F.
1

2

P.10
3
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2
3
P.12
NA
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RISK BEHAVIORS
Suicide Risk
Self-Injurious
Behavior
Other Self-Harm
Danger to Others
Fire Setting
Sexually Reactive
Behavior
Sexual Aggression
Delinquent Behavior
Bullying
Runaway
Problematic Social
Behavior
Eating Disturbance
0

1

2

P.13
3
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ADVERSE CHILDHOOD EXPERIENCES
P.16
This section is based on the child’s exposure to
adverse childhood experiences during the child’s
entire LIFETIME so far.
0= no evidence
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
CANS-NY 6 to 21 Score Sheet
VERSION: November 2, 2016
1= evidence or suspicion
0
1


Sexual Abuse


Physical Abuse


Emotional Abuse/Neglect


Neglect
Witness to Abuse of Another


Child


Medical Trauma
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Domestic Violence

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Community Violence

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Exploitation
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School Violence
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Natural or Manmade Disasters

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Criminal Activity

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Parental Incarceration
Disruptions in Caregiving/


Attachment

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Death of a Loved One

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Substance Exposure
Sexual Orientation/Gender

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Identity or Expression
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Bullied
Page |3
CANS-NY Score Sheet
G.
84
85
86
87
88
89
90
91
84.
A
B
C
D
E
F
G
85.
A
B
C
D
E
F
G
H
I
J
86.
A
B
C
D
AGES 6 to 21
SCREENING QUESTIONS FOR MODULES
0
1
2



Trauma Symptoms



Behavioral Health



Substance Use



Developmental



Medical Health
Self-Care Activities



of Daily Living
Transition to Adulthood
Independent Activities
of Daily Living
MODULES
Complete Modules 84-89
if relevant screening
questions in Section G are
rated as 1, 2, or 3.

If the Trauma Symptoms
Module is completed, the
Behavioral Health Module
needs to be completed as
well.
Youth is
13 or
younger
Youth is
14 or
older
Complete Modules 90 and
91 if Youth is aged 14-21.


TRAUMA SYMPTOMS MODULE
0
1


Traumatic Grief


Re-Experiencing


Hyperarousal


Avoidance


Numbing


Dissociation
Affective/


Physiological
Dysregulation
BEHAVIORAL HEALTH MODULE
0
1


Psychosis
Attention/


Concentration


Impulsivity


Depression


Anxiety


Oppositional


Conduct


Emotional Control


Anger Control


Attachment
SUBSTANCE USE MODULE
0

Severity of Use

Duration of Use

Peer Influences

Stage of Recovery
P.19
3





1




87.
2


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P.21
3

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
2

P.24
3

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

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




2




P.27
3




CANS-NY 6 to 21 Score Sheet
A
B
C
D
E
F
G
88.
A
B
C
D
E
F
G
H
89.
A
B
C
D
E
F
G
H
VERSION: November 2, 2016
84. Trauma Symptoms
85. Behavioral Health
86. Substance Use
87. Developmental
88. Medical Health
89. Activities of Daily Living
90. Transition to Adulthood
91. Independent Activities of
Daily Living
DEVELOPMENTAL MODULE
0

Cognitive

Agitation

Self-Stimulation

Motor

Communication
Developmental

Delay

Sensory
MEDICAL HEALTH MODULE
0

Life Threatening

Chronicity

Diagnostic Complexity

Emotional Response
Impairment in

Functioning

Intensity of Treatment
Organizational

Complexity

Family Stress
1





2





P.28
3











1




2




P.30
3

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SELF-CARE ACTIVITIES OF DAILY LIVING MODULE
P.32
0
1
2
3




Eating




Toileting




Bathing




Hygiene




Dressing




Mobility




Positioning




Transferring
Page |4
CANS-NY Score Sheet
AGES 6 to 21
VERSION: November 2, 2016
For Youth aged 14-21,
Complete Modules 90 & 91
90.
A
B
C
D
E
F
G
H
I
J
K
L
91.
A
B
C
D
E
F
TRANSITION TO ADULTHOOD MODULE
P.35
0
1
2
3
NA
Knowledge of
   
Condition
Medication
   
Adherence
   
Youth Involvement
Self-Care
   
Management
Youth Relationship
   
to the System
   
Career Aspirations
   
Employment
   
Living Skills
Educational
   
Attainment
   
Prevocational
Intimate
   

Relationships
   
Transportation
INDEPENDENT ACTIVITIES OF DAILY LIVING
MODULE
0
1
2



Meal Preparation



Shopping



Housework



Money Management
Communication



Device Use



Housing Safety
P.39
3




CANS-NY 6 to 21 Score Sheet

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Page |5