Adoption Assistance Amendment Request - Confirmation of Needs

Behavioral Characteristics

(Ages Birth to 4 - 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 (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 Toddlers are excessively withdrawn and unable to relate to familiar adults.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...

Recreational Play (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...

Preschool / Childcare

Overall Functioning (PAST 30 DAYS)

No evidence of problem with functioning in current preschool or childcare environment. Any concerns are age / developmentally appropriate or this information is unknown to me.

Mild problems with functioning in current preschool or childcare environment.

Moderate to severe problems with functioning in current preschool or childcare. Child has difficulties maintaining behavior, creating significant problems for others.

Profound problems with functioning in current preschool / childcare. Child is at immediate risk of being removed from program due to behaviors or needs.

Please explain why...

Attendance (PAST 30 DAYS)

Child attends preschool / childcare regularly. Any concerns are need / age appropriate or this information is unknown to me.

Child has some problems attending preschool / childcare, but generally is present.

Child is having problems with preschool / childcare attendance and is missing at least 2 days / week on average.

Child is absent most of the time and this causes a significant challenge in achievement, socialization and following routine.

Please explain why...

Compatibility (PAST 30 DAYS)

Child’s preschool / childcare meets the needs of the child or this information is unknown to me

Child’s preschool / childcare is marginal in its ability to meet the unusual needs of the child and / or the environment may be weak in areas.

Child’s preschool / childcare does not meet the unusual needs of the child in most areas and the environment may not support the child’s growth or promote learning.

The child’s preschool / childcare is contributing to problems for the child in one or more areas.

Please explain why...

Behavior (PAST 30 DAYS)

Child is behaving well in preschool / child care. Any concerns are age appropriate or this information is unknown to me.

When child is in preschool / child care, he / she behaves adequately although some behavior problems exist.

When child is in preschool / child care, he / she has moderate behavioral problems and is disruptive. Many interventions have been put in place.

When child is in preschool / child care, he / she is having severe problems with behavior and is frequently or severely disruptive. Threat of expulsion.

Please explain why...

Achievement (PAST 30 DAYS)

Child is doing well learning new skills. Any concerns are age appropriate or this information is unknown to me.

Child is doing adequately learning new skills with some challenges. Child may be able to do well with extra adult support.

Child is having moderate problems learning new skills. Child may not be able to retain concepts / skills or meet expectations in some areas even with adult support.

Child is having severe achievement problems. Child may be completely unable to understand or participate in skill development in most or all areas.

Please explain why...

Relationship 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...

Relationship with Peers (PAST 30 DAYS)

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

Child has occasional difficulties relating with at least one peer.

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

Child has very difficult relations with all peers. Relations with peers currently prevents child from learning.

Please explain why...

Other Behaviors

Atypical Behaviors (PAST 30 DAYS)

(e.g., repetitive head banging, spinning, hand flapping, finger-flicking, rocking, toe walking, staring at lights, repetitive speech)

Child has no evidence of atypical behaviors. Any concerns are age appropriate or this information is unknown to me.

History or reports of atypical behaviors from others that have not been observed by the individual completing this form.

Clear evidence of atypical behaviors reported by caregivers that are observed on an ongoing basis.

Clear evidence of atypical behaviors that are consistently present and interfere with the infants / child’s functioning on a regular basis.

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. Children under the age of 3 are scored here.

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 (past 6 weeks) 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 which interferes with child’s social and emotional development.

Please explain why...

PICA (PAST 30 DAYS)

No evidence that the child eats unusual or dangerous materials. Any concerns are age appropriate or this information is unknown to me. Children under 18 months old are scored here.

Child has a history of eating unusual or dangerous materials but has not done so in the last 30 days.

Child has eaten unusual or dangerous materials consistent with a diagnosis of Pica in the last 30 days.

Child has become physically ill during the past 30 days by eating dangerous materials.

Please explain why...

Self-Harm (PAST 30 DAYS)

There is no evidence of self-harm behaviors. Any concerns are age appropriate or this information is unknown to me.

Mild level or history of self-harm behaviors.

Moderate level of self-harm behaviors such as head banging that cannot be impacted by caregiver and interferes with child’s functioning.

Severe level of self-harm behavior that puts the child’s safety and wellbeing at risk.

Please explain why...

Aggressive Behavior (PAST 30 DAYS)

No evidence of aggressive behavior towards people or animals. Any concerns are age appropriate or animals or this information is unknown to me.

Mild concerns or history of aggressive behavior towards people or animals that have not yet interfered with functioning.

Clear evidence of aggressive behavior towards animals or others. Behavior is persistent and caregiver’s attempts to change behavior have not been successful.

Child has significant aggressive behaviors towards animals or others and caregivers have difficulty managing this behavior.

Please explain why...

Intentional Social Misbehavior (PAST 30 DAYS)

No evidence of problematic social behavior. Any concerns are age appropriate or this information is unknown to me. Children under the age of 3 are scored here.

Mild level of problematic social behavior that might include inappropriate comments to others or unusual behavior that results in sanctions to the child.

Moderate level of problematic social behavior that is causing problems in the child’s life. Child may be intentionally getting in trouble in school or at home.

Severe level of problematic social behavior that results in serious and / or repeated sanctions to the child.

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

Preschool / Childcare

Other Behaviors

DCF-F-2680-E (R. 05/2025)