Comprehensive Child and Adolescent Needs and Strengths (CANS) Referral
Name client being referred:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Social Security Number
*
If unknown fill with all 9's
Age:
Gender:
*
Current Grade:
MCO:
Medicaid Number:
*
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Current Placement / Living Situation
*
Parent / Guardian
Other Relative's Home
Foster Care
Residential Treatment
Inpatient
Detention Home
Other
Primary Contact
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best Time To Call:
Email
*
example@example.com
Relationship to Child:
Parent or Legal Guardian Information
Same as Client's Current Placement Listed Above?
Different from Current Placement Listed Above?
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Parent or Legal Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Person's relationship to the child
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Referral Source Information (Complete this section so we may contact you.)Your Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship to child
*
Your Agency Name
*
Reason for Referral - Presenting Problems: (Check all that apply)
*
Parent/Child conflict
Defiance
Aggression
School Problems
Peer Problems
Parenting
Substance Use
Social Skills
Basic Needs
Grief, Loss, Separation
Trauma
Mood Disorder
Behavior Disorder
Risk - Taking Behaviors
Legal Problems/Juvenile Court Involvement
Reason for Referral - Risk/Safety Factors/Severity of Risk (Check all that apply)
*
History of Suicide Threats/Attempts
Medically Fragile
Pregnancy
Homicidal/Assaultive/Domestic Violence
Gang Involvement
SUD Risk/Withdrawal Symptoms/Need for Detox
N/A
IV Drug Use (type of drug)
Describe Risk Factors
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Other Agencies Involved with Client
Ohio Dept. of Job & Family Services
Juvenile Court
Mental Health Treatment
Substance Use Disorder Treatment
Other
Agency Contact Information 1
Agency Contact Information 2
Agency Contact Information 3
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Best Availability for Sessions: Which days of the week, best time of day, after school, evenings, weekends, etc. Please be as specific as possible.
Person to be contacted for scheduling appointments.
*
Parent/Guardian listed above
Other
Name of person to contact
First Name
Last Name
Relation to Client
Phone number for contact
Please enter a valid phone number.
Format: (000) 000-0000.
Report Recipients (Check all that apply)
Parent/Guardian
Referral Sources
Other (name, & email address)
Submit
Should be Empty: