Initial Re-assessment Discharge Illinois Medicaid Comprehensive Assessment of Needs and Strengths (IM+CANS) 1. GENERAL INFORMATION Client First and Last Name: Date of Birth: RIN: Gender: Referral Source: Date First Contact: Trial Number: Primary Language: Interpreter None required Spoken Language: TDD/TYY Services: American Sign Language Other: Address: City: State: Zip Code: County: Ethnicity: American Indian/Alaska Native Hispanic White US Citizen: Hispanic Race: Asian Hawaiian Native/Other Pacific Islander Other: Yes Non-Hispanic No Black/African American Multi-Race Single Divorced Widowed Insurance Coverage and Company: Household Size: Household Marital N/A Married Domestic Partnership Income: Status: Own guardian Youth in Care Self-employed Military Employed full-time Guardianship Biological Parent court appointed Student Retired Employed part-time Status: Status: Adoptive Parent Other: Homemaker Unable to work Unemployed alone Residential/Institutional Setting (residential, nursing home, shelter) Living Independent Living Community integrated living arrangement (CILA) Lives with parent(s), relative(s), or guardian(s) Foster Care operated facility (mental health/dev. disability) Homeless Other: Jail or correctional facility Education Never attended Grade 4 5 H.S. diploma/GED Trade/technical training Master’s/Doctoral degree – Level: Pre-K/Kindergarten Grade 6 8 Some college Professional certificate – (last completed) 1 3 Grade 9 12 Associate’s degree Bachelor’s degree – – First and Last Name: Relationship to Client: Phone Number: Parent, Parent Guardian Significant Guardian, or Significant Address: City: Zip Code: County: Other Info. First and Last Name: Relationship to Client: Phone Number: Contact Address: City: State: Zip Code: Living in Name Age Relation to Client Home Yes No Yes No Yes No Members of Yes No Family Yes No Constellation Yes No Yes No Yes No Yes No Established Agency Contact Name Supports Physician School/Daycare Counselor/Therapist Child Welfare Worker ISC/PAS Agent Probation Officer Other:
Initial Re-assessment Discharge Illinois Medicaid Comprehensive Assessment of Needs and Strengths (IM+CANS) 1. GENERAL INFORMATION Client First and Last Name: Date of Birth: RIN: Gender: Referral Source: Date First Contact: Number: Primary Language: Interpreter Services: None required American Sign Language TDD/TYY Spoken Language: Other: Address: City: State: Zip Code: County: US Citizen: Yes No Race: American Indian/Alaska Native Asian Black/African American Hispanic Hawaiian Native/Other Pacific Islander Multi-Race White 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 court appointed Other: Status: Self-employed Student Homemaker Military Retired Unable to work Employed full-time Employed part-time Unemployed Living alone Independent Living Lives with parent(s), relative(s), or guardian(s) 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 Phone Number: Address: City: Zip Code: County: 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 Physician School/Daycare Counselor/Therapist Child Welfare Worker ISC/PAS Agent Probation Officer Other: Trial
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