Initial Update Re-assessment Illinois Medicaid Comprehensive Assessment of and Strengths (IM+CANS) 1. GENERAL INFORMATION Client First and Last Name: Date of Birth: RIN: Gender: Referral Source: Date First Contact: Phone Number: Primary Language: Interpreter Services: None required American Sign Language TDD/TYY Spoken Language: Address: City: State: Zip Code: County: US Citizen: Yes No Race: American Indian/Alaska Native Asian American Hispanic Hawaiian Native/Other Pacific Islander Multi-Race Other: Ethnicity: Hispanic Non-Hispanic Insurance Coverage and Company: N/A Household Size: Household Income: Marital Status: Single Married Divorced Domestic Partnership Widowed Guardianship Status: Own guardian Biological Parent Adoptive Parent Youth in Care Other court appointed Status: Self-employed Student Homemaker Military Retired Unable to work Employed full-time Employed part-time Unemployed Living Arrangement: Lives alone Independent Living Lives with parent(s), relative(s), or guardian(s) State operated facility (mental health/dev. disability) Jail or correctional facility Residential/Institutional Setting (residential, nursing home, shelter) Community integrated living arrangement (CILA) Foster Care Homeless Other: Education Level: (last completed) Never attended Pre-K/Kindergarten 1 – 3 Grade 4 – 5 Grade 6 – 8 Grade 9 – 12 H.S. diploma/GED Some college Associate’s degree Trade/technical training Professional certificate Bachelor’s degree Master’s/Doctoral degree Parent, Guardian, or Significant Other Info. First and Last Name: Relationship to Client: Parent Guardian Significant Other Phone Number: Address: City: State: Zip Code: County: Emergency Contact First and Last Name: Relationship to Client: Phone Number: Address: City: State: Zip Code: Members of Family Constellation Name Age Relation to Client Living in Home Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Established Supports Agency Contact Name Phone Email Physician School/Daycare Counselor/Therapist Welfare Worker ISC/PAS Probation Officer Other: Trial
12. MENTAL HEALTH ASSESSMENT SUMMARY Summary analysis and conclusion regarding the medical necessity of services. Tie all key information about the client’s mental health needs and diagnosis here. 13. ADDITIONAL CLIENT FUNCTIONING EVALUATIONS RECOMMENDED BY LPHA: No additional evaluations 14. SUMMARY OF PRIORITIZED CANS NEEDS AND STRENGTHS 14a. CANS Actionable Items to Consider for Treatment Planning Background – Trauma Experiences Background – Other Needs Item: Y N Item: 2 3 Item: Y N Item: 2 3 Item: Y N Item: 2 3 Treatment Target Needs Anticipated Outcome Needs Item: 2 3 Item: 2 3 Item: 2 3 Item: 2 3 Item: 2 3 Item: 2 3 Item: 2 3 Item: 2 3 Item: 2 3 Item: 2 3 Centerpiece/Useful Strengths Strengths to Item: 0 1 Item: 2 3 Item: 0 1 Item: 2 3 Item: 0 1 Item: 2 3 Item: 0 1 Item: 2 3 Caregiver Resources Caregiver Item: 0 1 Item: 2 3 Item: 0 1 Item: 2 3 Item: 0 1 Item: 2 3 15. INDIVIDUAL TREATMENT PLAN 15a. Client and Family Vision Statement For Treatment 15b. Client and Family Service Preferences.
16. Treatment Goals and Objectives Treatment Plan Date:___________________ All treatment goals and objectives should be stated in client/family language and should relate back to the CANS actionable items identified in box 14a. Goals are specific, observable outcomes related to functioning that result from targeting symptoms and behaviors. Objectives are the specific steps to reach the goal. CANS Item(s): CLIENT GOAL 1: Goal Status: Continue Discontinue Completed Date: Clinical Objectives Objective 1a. Objective 1b. Objective 1c. CANS Item(s): CLIENT GOAL 2: Goal Status: Continue Discontinue Completed Date: Clinical Objectives Objective 2a. Objective 2b. Objective 2c. CANS Item(s): CLIENT GOAL 3: Goal Status: Continue Discontinue Completed Date: Clinical Objectives Objective 3a. Objective 3b. Objective 3c. CANS Item(s): CLIENT GOAL 4: Goal Status: Continue Discontinue Completed Date: Clinical Objectives Objective 4a. Objective 4b. Objective 4c. CANS Item(s): CLIENT GOAL 5: Goal Status: Continue Discontinue Completed Date: Clinical Objectives Objective 5a. Objective 5b.