Adoption Assistance Amendment Request – Confirmation of Needs

Emotional 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 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

Affect Regulation (PAST 30 DAYS)

Child has no problems with emotional response. Concerns are age / developmentally appropriate or this information is unknown to me.

Child has mild to moderate problems with emotional response regulation.

Child has significant problems with emotional response regulation but can control affect at times. Problems are interfering with child’s functioning.

Child has severe problems regulating affect / emotional response even with caregiver’s support.

Please explain why...

Re-experiencing the Trauma (PAST 30 DAYS)

There is no evidence that child re-experiences the trauma. Concerns are age / developmentally appropriate or this information is unknown to me.

Child experienced some indications that the trauma was being re-experienced in the form of sleep disruption or play after the trauma but is no longer present. Subtle changes in child’s functioning.

Child experiences consistent indications that the trauma is being re- experienced: sleep disturbance, nightmares. Play mimicking trauma experienced.

Child experiences repeated and severe incidents of re- experiencing trauma that significantly interferes with functioning and cannot be managed by caregivers.

Please explain why...

Avoidance (PAST 30 DAYS)

No evidence of avoidant behavior. Concerns are age / developmentally appropriate or this information is unknown to me.

Mild problems with avoiding some situations either after the trauma or presently on an infrequent basis. Infants due to limited mobility rarely exhibit this symptom.

Moderate problems with avoidant behavior that occurs on a consistent basis when child is exposed to triggers related to the trauma. Caregiver can support the child.

Severe problems with avoidant behavior that occurs consistently but cannot be mediated by caregivers and causes significant distress.

Please explain why...

Increased Arousal (PAST 30 DAYS)

No evidence of increased arousal. Concerns are age / developmentally appropriate or this information is unknown to me.

Child may have a history of increased arousal or currently shows this behavior on an infrequent basis.

Child demonstrates increased arousal most of the time. Infants appear wide eyed, over reactive to stimuli, and have exaggerated startle response. Older children may have all of the above with behavioral reactions such as tantrums.

Child demonstrates increased arousal most of the time with significant impairment in their functioning that cannot be mediated by the caregiver.

Please explain why...

Numbing Response (PAST 30 DAYS)

No evidence of numbing response. Concerns are age / developmentally appropriate or this information is unknown to me.

Child exhibits some problems with numbing. Child may have a restricted range of affect or an inability to express or experience certain emotions (e.g., anger or sadness).

Child has moderate difficulties with numbing responses. Child may have blunted or flat emotional state or have difficulty experiencing intense emotion or feel consistently detached or estranged from others.

Child has significant numbing responses or multiple symptoms of numbing. Diminished interest or participation in activities.

Please explain why...

Child's Current Functioning / Needs

Regulatory (PAST 30 DAYS)

Child has no evidence of regulatory problems including ability to control bodily functions such as eating, sleeping, eliminating, sensitivity to external stimulation, etc. or this information is unknown to me.

Some problems with regulation. Infants may have unpredictable patterns and be difficult to console. Older children may require a great deal of structure and need more support than other children in coping with frustration and difficult emotions.

Moderate problems with regulation. Children may have severe reactions to stimuli and emotions that interfere with their functioning and ability to progress developmentally. Unpredictable patterns in eating and sleeping routines that disrupt the rest of the family.

Profound problems with regulation are present that place the child’s safety, well-being and / or development at risk.

Please explain why...

Eating (PAST 30 DAYS)

No evidence of problems relating to eating. Concerns are age / developmentally appropriate or this information is unknown to me.

Mild problems with eating that have been present in the past or are currently present some of the time causing mild impairment in functioning.

Moderate problems with eating are present and impair the child’s functioning. Children may seriously overeat, refuse most foods and not have a clear pattern of when they eat.

Severe problems with eating are present putting the child at risk developmentally. The child and family are very distressed and unable to overcome problems in this area.

Please explain why...

Elimination / Bathrooming (PAST 30 DAYS)

There is no evidence of elimination problems. Any concerns are age / developmentally appropriate or this information is unknown to me. (This does not include potty training concerns.)

Child may have a history of elimination difficulties but is presently not experiencing this other than on rare occasions.

Child demonstrates problems with elimination on a consistent basis that is interfering with the child’s functioning. (Lack of routine resulting in constipation, encopresis and enuresis.)

Child demonstrates significant difficulty with elimination to the extent that child / parent are in significant distress or interventions have failed.

Please explain why...

Sensory Reactivity (PAST 30 DAYS)

There is no evidence of sensory reactivity that is under or over reactive. Any concerns are age / developmentally appropriate or this information is unknown to me.

Child may have a history of sensory issues or mild issues currently that are controlled by caregiver support.

Child demonstrates under / over reactivity to sensory input in one or more area which impairs the child’s functioning.

Child demonstrates significant reactions to sensory input so that the caregiver is unable to help the child.

Please explain why...

Emotional Control (PAST 30 DAYS)

Child has no problem with emotional control. Any concerns are age / developmentally appropriate or this information is unknown to me.

Child has mild problems with emotional control that can be overcome with caregiver support.

Child has a moderate level of problems with emotional control that interferes most of the time with functioning (difficult to console, does not respond to caregiver support, becomes physically aggressive out of frustration).

Child has significant level of emotional control problems that are interfering with development. Caregivers are not able to help the child.

Please explain why...

Sleep (PAST 30 DAYS)

Child gets a full night’s sleep each night. Any concerns are age / developmentally appropriate or this information is unknown to me. Children 12 months or younger are scored here.

Child has some problems sleeping. Toddlers resist sleep and consistently need a great deal of adult support to sleep. Preschoolers may have a history of poor sleep or continued problems 1-2 nights per week.

Child is having problems with sleep that might include difficulty falling asleep, night waking, night terrors or nightmares on a regular basis (4 or more times per week).

Child is experiencing significant sleep problems that result in sleep deprivation that affects the child’s functioning. Parents have exhausted numerous strategies for assisting child.

Please explain why...

Attachment (PAST 30 DAYS)

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

Mild problems with attachment. Children may be overly reactive to separation or seem preoccupied with parent. Boundaries may seem inappropriate.

Moderate problems with attachment and may fail to demonstrate stranger anxiety or have extreme reactions to separation resulting affecting development, may avoid caregivers and have inappropriate boundaries putting them at risk.

Severe attachment problems. Children attachment to anyone or no one in an extreme manner. Child meets criteria for Reactive Attachment Disorder.

Please explain why...

Depression / Withdrawn (PAST 30 DAYS)

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

Child may be depressed or has experienced situations that may lead to depression. Infants may appear withdrawn and slow to engage at times. Older children are irritable or do not demonstrate a range of emotional response / affect.

Moderate problems with depression are present. Children may have negative verbalizations, no emotional response, dark / sad play and demonstrate little enjoyment in play and interactions.

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

Please explain why...

Anxiety (PAST 30 DAYS)

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

History or suspicion of anxiety problems or mild to moderate anxiety. Child may appear anxious in certain situation but has the ability to be soothed / calmed.

Anxiety with significant fearfulness that has interfered significantly in child’s ability to function. Child may be irritable, over reactive to stimuli, uncontrollable crying and significant separation anxiety.

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...

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-2681-E (R. 05/2025)