Adoption Assistance Amendment Request - Confirmation of Needs

Behavioral Characteristics

(Ages 5 to 21 - CANS Version)

Use of form: This confirms the special care needs of the child identified below. The Confirmation of Needs form is to be completed by an appropriate professional (e.g., physician, therapist, psychologist, school personnel, etc.). Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin States].

Instructions: Select the appropriate item in each category that most closely reflects the child's current functioning and/or needs. If the child's needs or functioning are appropriate, the first option should be selected. Sign, date, and provide your professional relationship to the child.

Contact Information

Child Name (Last, First MI)

Child Birthdate

Name of Person Completing Form

Daytime Telephone Number

Email Address?

Professional Relationship to Child

Affiliation?

Child's Current Functioning / Needs

Functioning in Current Living Situation (PAST 30 DAYS)

No evidence of problems functioning in current living situation.

Mild problems functioning in current home. Caregiver has concerns about child's behavior at home.

Moderate to sever problems functioning at home. Child's behavior is creating significant difficulties for others in the home.

Profound problems with functioning at home. Child is in immediate risk of being removed due to behavior.

Please explain why...

Social Functioning - Peer (LAST 30 DAYS)

Child has positive social relationships with peers. Any concerns are age / developmentally appropriate or this information is unknown to me.

Child is having minor problems in social relationships. Toddlers may need support to interact with peers and preschoolers may resist social situations.

Child is having moderate problems in social relationships. Toddlers may be aggressive and resist parallel play. Preschoolers may argue excessively and be unable to play in groups even with adult support.

Child is experiencing severe disruption in social relationships. Toddlers are excessively withdrawn and unable to relate to familiar adults. Preschoolers show no joy or sustained interaction with peers or adults.

Please explain why...

Social Functioning - Adult (LAST 30 DAYS)

No evidence that the child has problems with recreational play. Any concerns are age / developmentally appropriate or this information is unknown to me.

Child is doing adequately with recreational or play activities although some problems may exist. Child may be uninterested or poorly able to sustain play

Child is having moderate problems with recreational activities, may resist play, show little enjoyment or interest in activities.

Child has no interest in play or recreational activities. May spend most of time non-interactive or cannot demonstrate enjoyment or use play to further development.

Please explain why...

Involvement with the Legal / Juvenile Justice System

Seriousness (PAST 30 DAYS)

Child has engaged in status offenses (curfew, tobacco possession, etc.) or this information is unknown to me.

Child has engaged in delinquent behavior equivalent to a misdemeanor.

Child has engaged in delinquent behavior equivalent to a felony.

Child has engaged in delinquent behavior that places other citizens at risk of significant physical harm.

Please explain why...

History (PAST 30 DAYS)

Current criminal / delinquent behavior is the first known occurrence or this information is unknown to me / not applicable.

Child has engaged in multiple criminal / delinquent acts in the past year.

Child has engaged in multiple criminal / delinquent acts for more than 1 year but has had 3+ month periods without.

Child has engaged in multiple criminal / delinquent acts for more than 1 year without any period without involvement.

Please explain why...

Arrests (PAST 30 DAYS)

Child has no known arrests in past or this information is unknown to me.

Child has history of delinquency, but no arrests in the past 30 days.

Child has 1 to 2 arrests in the last 30 days.

Child has more than 2 arrests in the last 30 days.

Please explain why...

Planning (PAST 30 DAYS)

No evidence of any planning, criminal acts appear to be impulsive or this information is unknown to me.

Evidence suggests that the child knowingly enters situations where there is a likelihood that criminal behavior will occur.

Evidence of some planning of criminal / delinquent behavior.

Considerable evidence of significant planning of criminal / delinquent behavior. Behavior is premeditated.

Please explain why...

Community Safety (PAST 30 DAYS)

Child presents no risk to the community or this information is unknown to me.

Child engages in behavior that represents a risk to community property (theft, vandalism, etc.).

Child engages in behavior that places others in some danger of physical harm (risky driving, dangerous pranks).

Child engages in behavior that directly places community members in danger of significant physical harm.

Please explain why...

Legal Compliance (PAST 30 DAYS)

Child is fully compliant with their court order or no court orders are currently in place or this information is unknown to me.

Child is in general compliance with court order(s) (e.g. occasional missed appointments).

Child is in partial noncompliance with standing court orders (e.g. child is attending school but not court ordered treatment).

Child is in serious and / or complete noncompliance with standing court orders (e.g. parole violations).

Please explain why...

Peer Influences (PAST 30 DAYS)

Child’s primary peer social group does not engage in delinquent / criminal behavior or this information is unknown to me.

Child has peers in their primary peer group who do not engage in criminal / delinquent behavior, but some peers who do.

Child predominantly has peers who engage in delinquent behavior but child is not a member of a gang.

Child is a member of a gang whose membership encourages or requires illegal behavior as an aspect of gang membership.

Please explain why...

School

Attendance (PAST 30 DAYS)

Child attends school regularly or this information is unknown to me.

Child has some problems attending school, including a history of truancy, suspensions or expulsions but generally goes to school.

Child is having problems with school attendance, including frequent truancy, suspensions or expulsions and is missing at least 2 days / week on average.

Child is generally truant or refusing to go to school more than 3 days out of every week.

Please explain why...

Behavior (PAST 30 DAYS)

Child is behaving well in school. Any concerns are age appropriate or this information is unknown to me.

When child is in school, he / she behaves well although some behavior problems exist.

When child is in school, he / she has moderate behavioral problems and is disruptive. Child may have received discipline including suspensions.

When child is in school, he / she is having severe problems with behavior and is frequently or severely disruptive. Child is in danger of expulsion.

Please explain why...

Achievement (PAST 30 DAYS)

Child is doing well in school, any concerns are age appropriate or this information is unknown to me.

Child is doing well in school achievement, although some problems exist, such as failing to turn in work, disorganization or refusal to do some assignments.

Child is having moderate problems with school achievement. He / she may be failing some subjects.

Child is having severe achievement problems and may be failing most subjects or has failed more than 1 year within the past two years.

Please explain why...

Relationships with Teachers (PAST 30 DAYS)

Child has good relations with teachers. Any concerns are age appropriate or this information is unknown to me.

Child has occasional difficulties relating with at least 1 teacher or during at least one subject period.

Child has difficult relations with teachers that notably interferes with the child’s education.

Child has very difficult relations with all teachers or with their only teacher which prevents the child from learning.

Please explain why...

Other Behaviors

Sexual Development (PAST 30 DAYS)

No evidence of any problems with sexual development. Any concerns are age appropriate or this information is unknown to me.

Mild to moderate problems with sexual development that may include concerns about sexual identity or anxiety about the reactions of others.

Significant problems with sexual development that may include multiple and / or older partners or high-risk sexual behaviors.

Profound problems with sexual development that may include prostitution, very frequent risky sexual behavior, or sexual aggression.

Please explain why...

Impulsivity / Hyperactivity (PAST 30 DAYS)

No evidence of impulsivity / hyperactivity, any concerns are age appropriate or this information is unknown to me.

Some problems with impulsive, distractible or hyperactive behavior.

Clear evidence of problems with impulsive, distractible or hyperactive behavior that is interfering with the child’s ability to function.

Clear evidence of a dangerous level of impulsive behavior that can place the child at risk of physical harm.

Please explain why...

Oppositional Behaviors (PAST 30 DAYS)

No evidence of oppositional behaviors. Child displays age appropriate resistance towards adults or this information is unknown to me.

History or recent onset of defiance towards authority figures.

Clear evidence of oppositional and / or defiant behaviors which are interfering with the child’s functioning and/or causing emotional harm to others.

Clear evidence of a dangerous level of oppositional behavior involving the threat of physical harm to others.

Please explain why...

Conduct (PAST 30 DAYS)

No evidence of intentional misconduct. Any concerns are age appropriate or this information is unknown to me.

History / suspicion of problems associated with behavior including lying, stealing, manipulating others, sexual aggression, violence towards property people or animals.

Clear evidence of behavior which includes lying, stealing, manipulating others, sexual aggression, violence towards property people or animals.

Evidence of a severe level of behavior that places the child or community at significant risk of physical harm due to these behaviors.

Please explain why...

Anger Control (PAST 30 DAYS)

No evidence of any significant anger control problems. Any concerns are age appropriate or this information is unknown to me.

Some problems with controlling anger. Child may become verbally aggressive when frustrated.

Moderate anger control problems. Child’s temper can become violent and has caused significant trouble with peers, family and / or school.

Severe anger control problems. Child’s temper is likely associated with frequent fighting that is often physical. Others likely fear the child.

Please explain why...

Substance Use (PAST 30 DAYS)

No evidence of substance use or this information is unknown to me.

History or suspicion of substance use.

Clear evidence of substance abuse that interferes with functioning in any area of life.

Child requires detoxification OR is addicted to alcohol / drugs.

Please explain why...

Danger to Others (PAST 30 DAYS)

No evidence that the child presents a danger to others. Any concerns are age appropriate or this information is unknown to me.

History of homicidal ideation, physically harmful aggression or fire setting that has put self or others in danger of harm.

Recent homicidal ideation, physically harmful aggression or dangerous fire setting but not in the past 24 hours.

Homicidal ideation with a plan or physically harmful aggression within the past 24 hours.

Please explain why...

Sexual Aggression (PAST 30 DAYS)

No evidence of any history of sexually aggressive behavior. Any sexual contact has been age appropriate and consenting. No sexual contact with younger children, or this information is unknown to me.

History of sexually aggressive behavior (but not in the past year) OR sexually inappropriate behavior in the past year (e.g. harassing talk or excessive masturbation).

Child is engaged in sexually aggressive behavior in the past year but not in the past 30 days (use of force, coercion, unconsenting contact).

Child has engaged in sexually aggressive behavior in the past 30 days (use of force, coercion, unconsenting contact).

Please explain why...

Delinquent Behavior (PAST 30 DAYS)

No evidence of any delinquent behavior or this information is unknown to me.

History of criminal / delinquent behavior but no acts in the past 30 days.

Recent acts of criminal / delinquent behavior but no acts in the past 30 days.

Severe acts of criminal / delinquent behaviors that placed others at risk of significant loss or injury or place the child at risk of adult sanctions.

Please explain why...

Intentional Misbehavior (PAST 30 DAYS)

No evidence of problematic social behavior. Any concerns are age appropriate or this information is unknown to me.

Mild level of problematic social behavior (e.g. behavior that results in consequences by adults, inappropriate comments, unusual behavior in social settings).

Moderate level of problematic social behavior which is intentional and causing problems in the child’s life. Child is getting into trouble in school, at home and in the community.

Severe level of problematic social behavior that might result in significant consequences such as expulsion, removal from the home or community.

Please explain why...

Fire Setting

No evidence of fire setting. Any concerns are age appropriate or this information is unknown to me.

History of fire setting but not in the past 6 months.

Recent fire setting behavior (in the past 6 months) but not of the type that has endangered the child or others.

Acute threat of fire setting. Has set a fire that endangered the lives of others (e.g. attempting to burn down a house).

Please explain why...

Bullying

Child has never engaged in bullying at school or in the community. Any concerns are age appropriate or this information is unknown to me.

Child has been involved with groups that have bullied others either in school or the community; however, child has not had a leadership role in these groups.

Child has bullied other child in school or community. Child has bullied another by alone or led a group that bullied another.

Child has repeatedly utilized threats or actual violence to bully child in school and / or community.

Please explain why...

Running Away

Runaway (PAST 30 DAYS)

No evidence that the child runs away. Any concerns are age appropriate or this information is unknown to me.

History of runaway from home or other settings involving at least 1 overnight absence, at least 30 days ago.

Recent runaway behavior or ideation but not in the past 7 days.

Serious threat to runaway as shown by either recent attempts OR child is currently a runaway.

Please explain why...

Frequency

Child has only run once in the past year or this information is unknown to me / not applicable.

Child has run on multiple occasions in the past year.

Child runs often (two or more times per month) but not always.

Child runs at every opportunity.

Please explain why...

Consistency of Destination

Child always runs to the same location or this information is unknown to me / not applicable.

Child generally runs to the same location or neighborhood.

Child runs to the same community but the specific locations change.

Child runs to no planned destination.

Please explain why...

Safety of Destination

Child runs to a safe environment that meets their basic needs (e.g. food, shelter) or this information is unknown to me / not applicable.

Child runs to generally safe environments; however, they might be somewhat unstable or variable.

Child runs to generally unsafe environments that cannot meet their basic needs.

Child runs to very unsafe environments where the likelihood that he / she will be victimized is high.

Please explain why...

Involvement in Illegal Activities

Child does not engage in illegal activities while on the run or this information is unknown to me / not applicable.

Child engages in status offenses beyond those involved with the running itself (e.g. curfew violations, underage drinking).

Child runs to generally unsafe environments that cannot meet their basic needs.

Child engages in dangerous delinquent activities while on the run (e.g. prostitution, selling / buying drugs).

Please explain why...

Likelihood of Return on Own

Child will return from run on their own without prompting or this information is unknown to me / not applicable.

Child will return from run when found, but not without being found.

Child will make self difficult to find and / or might passively resist return once found.

Child makes repeated and concerted efforts to hide so as to not be found and / or resists return.

Please explain why...

Involvement with Others

Child runs by self with no involvement of others or this information is unknown to me / not applicable.

Others enable child to run by not discouraging child’s behavior.

Others are involved in child’s running by actively helping or encouraging child.

Child actively is encouraged to run by others. Others actively help running behavior.

Please explain why...

Realistic Expectations

Child has realistic expectations about the consequences of running behavior or this information is unknown to me / not applicable.

Child has reasonable expectations about the consequences of running, but may be hoping for a somewhat optimistic outcome.

Child has unrealistic expectations about the consequences of running behavior.

Child has obviously false or delusional expectations about the consequences of running behavior.

Please explain why...

Email Address of Child's Adoptive Parent

We will use this to send the child's adoptive parent an email that this form has been completed, once submitted.

Signature - Person Completing Form

Sign above

Date Signed

Adoption Assistance Amendment Request - Confirmation of Needs

Behavioral Characteristics

Contact Information

Child's Current Functioning / Needs

Involvement with the Legal / Juvenile Justice System

School

Other Behaviors

Running Away

DCF-F-2677-E (R. 05/2025)