Adoption Assistance Amendment Request – Confirmation of Needs

Physical / Personal Care 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?

Child's Current Functioning / Needs

Overall Development (PAST 30 DAYS)

Child has no developmental problems. Any concerns are age appropriate or this information is unknown to me.

Child has some problems with physical immaturity or there are concerns about possible delays and / or low IQ.

Child has developmental delays or mild cognitive disabilities.

Child has severe and pervasive developmental delays or profound cognitive disabilities.

Please explain why...

Cognitive Development (PAST 30 DAYS)

Child shows no evidence of cognitive development problems. Any concerns are age appropriate or this information is unknown to me.

Child has some signs that cognitive skills are not appropriate. Child may be unaware of surroundings, challenges in remembering routines and completing tasks such as sorting, recognizing colors.

Child has clear signs that development is not at the expected level. Child may be unable to understand simple routines or tasks.

Child has significant delays in cognitive functioning that are seriously interfering with their functioning. Child is completely reliant on caregiver to function.

Please explain why...

Autism Spectrum (PAST 30 DAYS)

Childs demonstrates no symptoms or behaviors that may indicate an autism spectrum disorder or this information is unknown to me.

Evidence of mild symptoms of an autism spectrum disorder. Child may meet criteria for what was formerly Asperger syndrome.

Child has been diagnosed by an appropriate professional as having an autism spectrum disorder.

Child has been diagnosed by an appropriate professional as having an autism spectrum disorder and the related symptoms or behaviors cause severe impairment in at least one area of life skills.

Please explain why...

Communication (PAST 30 DAYS)

Child’s ability to communicate is age appropriate or this information is unknown to me.

Child is able to understand others but may have limited ability for self-expression.

Child has limited abilities to understand others or to self-express.

Child is unable to communicate.

Please explain why...

Self-Care and Daily Living Skills (PAST 30 DAYS)

Child’s self-care / daily living skills appear to be age appropriate or this information is unknown to me.

Child requires excessive verbal prompting on self-care tasks or daily living skills.

Child requires assistance (physical prompting) on multiple self-care tasks or complete assistance on one self-care task.

Child requires complete assistance on more than one self-care task (eating, bathing, dressing, toileting).

Please explain why...

Medical Needs

Medical Needs (PAST 30 DAYS)

Child is healthy or this information is unknown to me / does not apply.

Child has some medical problems that require medical treatment (includes controlled asthma).

Child has chronic illness that requires ongoing medical intervention (diabetes, severe / uncontrolled asthma, life threatening allergies, HIV).

Child has life threatening illness or medical condition (active cancer, AIDS, etc.).

Please explain why...

List medical condition(s) (within the last 30 days)

Life Threatening (PAST 30 DAYS)

Child’s medical condition has no implications for shortening the child’s life or this information is unknown to me / does not apply.

Child’s medical condition may shorten life, but not until later in adulthood.

Child’s medical condition causes some risk of premature death before he / she reaches adulthood.

Child’s medical condition causes eminent risk of death.

Please explain why...

Chronicity (PAST 30 DAYS)

Child is expected to fully recover from the condition within the next 6 months or this information is unknown to me / does not apply.

Child is expected to fully recover from the condition after at least 6 months but less than 2 years.

Child is expected to fully recover from the condition but not within the next 2 years.

Child’s medical condition is expected to continue throughout the child’s lifetime.

Please explain why...

Diagnostic Complexity (PAST 30 DAYS)

Child’s medical diagnoses are clear and correct or this information is unknown to me / does not apply.

Some evidence exists to say that the child’s symptoms are complex and the diagnosis may not be entirely accurate.

There is substantial concern about the accuracy of the child’s medical diagnoses due to the complexity of symptoms.

It is currently not possible to accurately diagnose the child’s medical conditions.

Please explain why...

Emotional Response (PAST 30 DAYS)

Child is coping well with the medical condition or this information is unknown to me / does not apply.

Child is experiencing some emotions related to the medical condition, but these are not affecting other areas of life.

Child’s emotional response to the condition is interfering with treatment and other areas of life.

Child is having severe emotional response to the condition that is interfering with treatment and functioning.

Please explain why...

Impairment in Functioning (PAST 30 DAYS)

Child’s medical condition is not interfering with functioning in other areas of life or this information is unknown to me / does not apply.

Child’s medical condition is having a limited impact on functioning in one area of life (self care, social interaction, communication, etc).

Child’s medical condition is interfering with functioning in more than one area of life or is disabling in at least one domain.

Child’s medical condition has disabled the child in all other areas of life.

Please explain why...

Treatment Involvement (PAST 30 DAYS)

Child is actively involved in treatment or this is not applicable or this information is unknown to me.

Child is generally involved in treatment but may struggle to stay consistent.

Child is generally uninvolved although they are sometimes compliant with recommendations.

Child is currently resistant to all efforts to provide medical treatment.

Please explain why...

Intensity of Treatment (PAST 30 DAYS)

Child’s medical treatment involves taking daily medications or visiting a medical professional no more than weekly, or this information is unknown to me / does not apply.

Child’s medical treatment involves taking multiple medications or visiting a medical professional multiple times per week.

Child’s treatment is daily but non-invasive. Treatment can be administered by a caregiver.

Child’s medical treatment is daily and invasive and requires either a medical professional or trained caregiver to administer.

Please explain why...

Organizational Complexity (PAST 30 DAYS)

All medical care is provided by a single medical professional or this information is unknown to me / does not apply.

Child’s medical care is generally provided by a coordinated team of medical professionals who work for the same organization.

Child’s medical care requires collaboration of multiple professionals who work for more than one organization.

Child’s medical care requires the collaboration of multiple professionals who work for more than one organization and are not able to communicate effectively.

Please explain why...

Physical Needs

Physical Needs (PAST 30 DAYS)

Child has no physical limitations, any concerns are age appropriate or this information is unknown to me.

Child has some physical condition that places mild limitations on activities (hearing, vision impairment).

Child has physical condition that notably impacts activities (blindness, deafness or significant motor difficulties).

Child has severe physical limitations due to multiple physical conditions.

Please explain why...

Dental Needs (PAST 30 DAYS)

No evidence of any dental health needs or this information is unknown to me.

Child may have some dental health needs but they are not clearly known at this time.

Child has dental needs that require attention. Dental health is interfering with functioning in at least one life domain (eating, social interaction, etc.).

Child has serious dental health needs that require intensive and / or extended treatment / intervention.

Please explain why...

Daily Functioning (PAST 30 DAYS)

Child has age appropriate self-care skills. No indication of deficits or this information is unknown to me.

Child has minor indications of problems in self-care (dressing, bathrooming, bathing) compared to same age children.

Child demonstrates moderate or routine problems in self-care skills and relies on others for help more than expected for same age children.

Child has severe or constant problems in self-care skills and relies on others for help much more than is expected for same age children.

Please explain why...

Motor Skills (PAST 30 DAYS)

No evidence of fine or gross motor development problems. Any concerns are age appropriate or this information is unknown to me.

Child has some indicators that motor skills are challenging and there may be some concern that there is a delay.

Child has either fine or gross motor skill delays.

Child has significant delays in fine or gross motor development or both. Delay causes impairment in functioning.

Please explain why...

Communication (PAST 30 DAYS)

No evidence of communication problems exists. Any concerns are age appropriate or this information is unknown to me.

Child has a history of communication problems but currently is not experiencing problems.

Child has difficulty understanding or expressing self through language / gestures which interfere with functioning, including trouble interpreting facial gestures or initiating gestures to communicate needs.

Child has serious communication difficulties and is unable to communicate in any way including pointing and grunting.

Please explain why...

Failure to Thrive (PAST 30 DAYS)

No evidence of failure to thrive or this information is unknown to me.

Child may have experienced past problems with growth and ability to gain weight and is currently not experiencing problems.

Child is experiencing problems in their ability to maintain weight or growth. Child may be below the 5th percentile for age and sex and may weigh less than 80% of their ideal weight for age, have depressed weight for height.

Child may have one or more of the symptoms listed and is currently at serious medical risk.

Please explain why...

Labor and Delivery

Child and biological mother had a normal labor and delivery or this information is unknown to me.

Child or mother had some mild problems during delivery, but child does not appear affected by problems.

Child or mother had problems during delivery that resulted in temporary functional difficulties for the child or mother.

Child had severe problems during delivery that have resulted in long term implications for development.

Please explain why...

Parent / Sibling Disability (PAST 30 DAYS)

Child’s parents have no developmental disabilities. The child has no siblings or existing siblings are not experiencing any developmental or behavioral problems or this information is unknown to me.

Child’s parents have no developmental disabilities. Child has siblings who are experiencing some mild developmental or behavioral problems.

Child’s parents have no developmental disabilities. Child has a sibling who is experiencing a significant developmental or behavioral problem.

One or both of the child’s parents have been diagnosed with a developmental disability, or the child has multiple siblings who are experiencing significant developmental or behavioral problems.

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

Physical / Personal Care Characteristics

Contact Information

Child's Current Functioning / Needs

Medical Needs

Physical Needs

DCF-F-2682-E (R. 05/2025)