Massachusetts CHILD AND ADOLESCENT NEEDS AND STRENGTHS Ages Five through Twenty
Child Name: ____________________________________________________________________________________
Organization Name ___________________________________________ Other:_________________________
If yes to (a), is this solely the result of autism, mental retardation, specific learning disability,
hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic
impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a
serious emotional disturbance?
Yes No
(b) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers.
Yes No
If yes to (b), is this solely the result of autism, mental retardation, specific learning disability,
hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic
impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a
serious emotional disturbance?
Yes No
(c) Inappropriate types of behavior or feelings under normal circumstances. Yes No
If yes to (c), is this solely the result of autism, mental retardation, specific learning disability,
hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic
impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a
serious emotional disturbance?
Yes No
(d) A general pervasive mood of unhappiness or depression. Yes No
If yes to (d), is this solely the result of autism, mental retardation, specific learning disability,
hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic
impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a
serious emotional disturbance?
Yes No
(e) A tendency to develop physical symptoms or fears associated with personal or school problems.
Yes No
If yes to (e), is this solely the result of autism, mental retardation, specific learning disability,
hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic
impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a
serious emotional disturbance?
Yes No
5. Please check this box if you identified a functional impairment in question 2 or answered “yes” to
question 3→
The child /adolescent has SED under Part I.
6. Please check this box if you checked one or more “no” boxes in the right hand column of question 4 →
The child /adolescent has SED under Part II.
Clinician name, degree (print):
Clinician signature:
Date: _________________________
Updates January 9, 2012 CANS copyright is held by the Praed Foundation 4
click to sign
signature
click to edit
![]()
