CANS Request and Consent

CANS Request and Consent

BAILIFF COUNSELING
Russell Bailiff, M.S.S.W.
Licensed Clinical Social Worker Supervisor

Austyn Bailiff, M.A.
Licensed Professional Counselor, National Certified Counselor 

Please fill out the following form in order to set up your CANS Assessment. Once the form has been received, we will contact you and set up the appointment. Results will then be sent to the designated DFPS or Agency worker.
Your information
Your name*

First NameLast Name
Today’s Date*

MonthDayYear
Date
Your relationship to the Child*

Biological parentFoster parentFamily memberDFPS workerOther
Child information
Child's name*

First NameLast Name
Child's date of birth*

MonthDayYear
Date
Child’s age
Child gender

MaleFemaleGender FluidNon-binary GenderOther
Child's race/ethnicity*

American Indian or Alaskan NativeAsian or Pacific IslanderBlack, not of Hispanic originHispanic or LatinoWhite, not of Hispanic originOther
Caregiver information
Caregiver name*

First NameLast Name
Caregiver phone*
Please enter a valid phone number.
Caregiver email*
example@example.com
Caregiver relationship to the Child*

Biological parentFoster parentFamily memberOther
Let us know which methods are alright with you when trying to set up scheduling.*

Text me for schedulingEmail me for schedulingCall me for schedulingOther
Caregiver's present address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DFPS Worker information
Current DFPS worker*

First NameLast Name
DFPS Worker phone
Please enter a valid phone number.
DFPS worker email*
example@example.com
Child's removal date*

MonthDayYear
Date
What agency is managing the case?*
e.g., Methodist, Arrow, Azleway, Private placement, etc.
Child welfare involvement*

In CareNot in careChild welfare involvement but not in care
Assessment type*

Initial AssessmentRe-assessmentClosing AssessmentI'm not sure
Medicaid number (MCD)*
Child's Personal ID Number (PID)*
Who referred you to our services?
Signature

Read the information below and sign to verify your understanding and consent to proceed.
By signing below, I, {yourName}, the Legal Consentor for {childsName3}, do verify my understanding of, and consent to, the following on this day {todaysDate}.

Confidentiality: HIPAA provides some guidelines to protect privacy. Confidentiality is vital in conducting a CANS. There are a few reasons that may require the Assessor to break confidentiality. These are listed below:
1. Suspected abuse or neglect (to a child, dependent, and/or the elderly)
2. Suspected threat to harm yourself or another
3. A court order requiring broken confidentiality
4. If you or a family member is involved with CPS
Consent to CANS Assessment: I consent to a CANS Assessment or referral to another professional for the child listed above. I have read and acknowledge the terms above including the HIPAA explanation. I further attest that I am legally able to consent on behalf of the Child listed on this form.

Disclosure of Results: I consent for the results to be sent to the CPS Worker/Agency noted above.
Signature of Legal Consenter

Clear
Today's date*

MonthDayYear
Date
Should be Empty:

CANS Request and Consent

Your information

Child information

Caregiver information

DFPS Worker information

Signature