Adoption Assistance Amendment Request – Confirmation of Needs

Emotional 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 Statutes].

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 age 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?

Adjustment to Past Trauma

Adjustment to Past Trauma (Emotional Characteristic Over the PAST 30 DAYS)

Child has demonstrated no emotional concerns related to past traumatic life events. Any concerns are age appropriate or this information is unknown to me.

History or suspicion of problems associated with traumatic life events.

Clear evidence of adjustment problems due to traumatic life events which are interfering with the child’s functioning in at least one area of life.

Clear symptoms of Post Traumatic Stress Disorder, which may include flashbacks, nightmares, significant anxiety, and intrusive thoughts of trauma experience.

Please explain why...

Traumatic Grief / Separation (PAST 30 DAYS)

There is no evidence the child has experienced traumatic grief or separation from significant caregivers or this information is unknown to me.

Child is experiencing some level of traumatic grief due to death or loss of a significant person or distress from caregiver separation in a manner that is appropriate given the recent nature of loss or separation.

Child is experiencing a moderate level of traumatic grief or difficulties with separation in a way that impairs functioning in certain but not all areas including isolation or withdraw from others.

Child is experiencing significant traumatic grief or separation reactions. Child exhibits impaired functioning in several areas for a significant period of time following the loss or separation.

Please explain why...

Intrusions (PAST 30 DAYS)

There is no evidence that the child experiences intrusive thoughts of trauma or this information is unknown to me.

Child experiences some intrusive thoughts of trauma but they do not affect functioning.

Child experiences intrusive thoughts that interfere with the child’s ability to functioning in some areas of life.

Child experiences repeated and severe intrusive thoughts of trauma.

Please explain why...

Attachment (PAST 30 DAYS)

No evidence of attachment problems. Any concerns are age / developmentally appropriate or this information is unknown to me.

Mild problems with attachment. This could involve either mild problems with separation or mild problems of detachment.

Moderate problems with attachment. Child is having problems with attachment that require intervention. A child who meets the criteria for Attachment Disorder in DSM-IV would be rated here.

Severe problems with attachment. A child who is unable to separate or a child who appears to have severe problems with forming or maintaining relationships with caregivers.

Please explain why...

Dissociation / Emotional Disconnect from Situations (PAST 30 DAYS)

There is no evidence of dissociation/emotional disconnection to a stressful situation or this information is unknown to me.

Child may experience some symptoms of dissociation / emotional disconnection to a stressful situation.

Child clearly experiences episodes of dissociation / emotional disconnection to a stressful situation which are having an impact on the child’s ability to function in social situations or relate to others.

Profound dissociation / emotional disconnection to a stressful situation. The periods of dissociation are having a profound effect on the child’s ability to function or relate to others in several areas of life.

Please explain why...

Child's Current Functioning / Needs

Eating Disturbance (PAST 30 DAYS)

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

Mild level of eating disturbance. This could include some preoccupation with weight, calories, body size, binge eating patterns or eating non-food items that are not harmful (paper, small items).

Clear evidence of eating disturbance that could include restrictive eating, excessive exercise, vomiting, laxatives, etc, in order to maintain below normal weight or eating non-food items that cause pain or digestive problems.

Eating disturbance is disabling. Could include significantly low weight, excessive binge-purge behaviors (at least 1x/day), eating dangerous non-food items (sharp items or chemicals) and / or hospitalization.

Please explain why...

Sleep (PAST 30 DAYS)

Child gets a full night’s sleep each night or this information is unknown to me.

Child has some problems sleeping. This may include occasionally waking, bedwetting or nightmares.

Child’s sleep is often disrupted and child seldom obtains a full night of sleep.

Child is generally sleep deprived. Sleeping is difficult for the child and he / she is not able to get a full night sleep.

Please explain why...

Psychosis / Hallucinations / Delusions (PAST 30 DAYS)

No evidence of hallucinations or delusions, or this information is unknown to me.

History or suspicion of hallucinations or delusions.

Clear evidence of hallucinations or delusions.

Clear evidence of dangerous hallucinations or delusions which places the child or others at risk of physical harm.

Please explain why...

Depression (PAST 30 DAYS)

No evidence or concern about depression. Any concerns are age appropriate or this information is unknown to me.

History or suspicion of depression or mild to moderate depression associated with a recent negative life event.

Clear evidence of depression associated with either depressed mood which has interfered significantly in child’s ability to function in at least one area of life.

Clear evidence of a disabling level of depression that makes it virtually impossible for the child to function in any area of life.

Please explain why...

Anxiety (PAST 30 DAYS)

No evidence or concern about anxiety, any concerns are age appropriate or this information is unknown to me.

History or suspicion of anxiety problems or mild to moderate anxiety associated with a recent negative life event.

Clear evidence of anxiety associated with significant fearfulness or anxious mood that has interfered significantly in child’s ability to function in at least one area of life.

Clear evidence of debilitating level of anxiety that makes it virtually impossible for the child to function in any area of life.

Please explain why...

Somatization – Expressing Feelings Through Physical Symptoms

No evidence of unexplained physical symptoms associated with emotional stress. Any concerns are age / developmentally appropriate or this information is unknown to me.

Mild level of physical problems (unexplained headaches, stomach problems, joint, limb or chest pain without medical cause) associated with emotional stress.

Moderate level of physical problems (persistent physical symptoms without medical cause and associated with emotional stress). Somatoform disorder diagnosis.

Severe physical symptoms associated with emotional stress and causing significant disturbance in school or social functioning.

Please explain why...

Behavioral Regression

Child’s behaviors are consistent and age appropriate or this information is unknown to me.

Child has some regression in age-level behavior (e.g. thumb sucking, whining when age inappropriate).

Child has moderate regression in age-level behavior including loss of ability to engage with peers, stopping play or exploration, or occasional bedwetting.

Child has significant regression in behaviors as demonstrated by significant periods of changes in speech or loss of bowel or bladder control.

Please explain why...

Affect Dysregulation / Emotions Are Not Appropriate to the Situation (PAST 30 DAYS)

No evidence of inappropriate emotional response, any concerns are age appropriate or this information is unknown to me.

Child has mild to moderate problems demonstrating emotional responses that are appropriate to a given situation.

Child has severe problems with appropriate emotional response but can control affect at times.

Child’s emotional response to situations are mostly inappropriate and interfere in several areas of life.

Please explain why...

Suicide Risk – Do Not Include Cutting Behaviors in This Category (PAST 30 DAYS)

No evidence of suicidal thoughts or actions or this information is unknown to me. (Cutting behavior is not a suicidal action).

History but no recent ideation or gesture.

Recent ideation or gesture but not in the past 24 hours.

Current ideation or intent OR command hallucinations that involve self-harm.

Please explain why...

Self-Injurious Behavior (PAST 30 DAYS)

No evidence of self-injurious behavior or this information is unknown to me.

History of self-mutilation.

Engaging in self-mutilation that does not require medical attention.

Engaging in self mutilation that requires medical attention.

Please explain why...

Other Self Harm (PAST 30 DAYS)

No evidence of behavior that places child at risk of physical harm. Any concerns are age appropriate or this information is unknown to me.

History of engaging in reckless or risk-taking behaviors that put the child at risk of physical harm.

Engages in reckless or risk-taking behaviors that put the child at risk of serious physical harm.

Engaged in reckless or risk-taking behavior that places child at immediate risk of death.

Please explain why...

Exploited

There is no evidence of a history of exploitation or history of victimization over the past year or this information is unknown to me.

Suspicion or history of exploitation, but person has not been exploited to any significant degree during the past year. Person is not presently at risk for re-victimization.

This level indicates a person who has been recently exploited (within the past year) but is not at acute risk of re-exploitation. (Physical or sexual abuse, significant psychological abuse, extortion violent crime, etc.).

This level indicates a person who has been recently exploited and has an acute risk of re-exploitation. (Working as a prostitute, in an abusive relationship, etc.).

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

Emotional Characteristics

Contact Information

Adjustment to Past Trauma

Child's Current Functioning / Needs

DCF-F-2678-E (R. 05/2025)