CANS assessment appointment request

Complete this form to request a Child and Adolescent Needs and Strengths (CANS) assessment appointment for children aged 17 or younger.

Your information is secure and will only be used to schedule your CANS assessment. You will receive a reply from the CANS scheduling team within 2 business days of this request.

Disclaimer: Completing this form does not guarantee an appointment.

Before you submit this form, please make sure the person is assigned to Maximus for assessment.

If the person has a care manager, ask the care manager to confirm the assignment.
If the person does not have a care manager or CCO, contact the local DDRO  to check the status.

We cannot schedule an assessment unless the person is currently assigned to Maximus.

Fields marked with an asterisk (*) are required.

1. Requester information

Your first and last name

Relationship to child who needs the assessment

Other relationship

Preferred contact information

Phone number

Email address

2. Child who needs the assessment

First and last name

Date of birth

TABS ID (if available)

Child's caregivers

Caregiver 1 first and last name

Caregiver 1 email address

Caregiver 1 phone number

Caregiver 2 first and last name

Caregiver 2 email address

Caregiver 2 phone number

Caregiver 3 first and last name

Caregiver 3 email address

Caregiver 3 phone number

3. Care management information

Care Coordination Organization (CCO) name

Care manager first and last name

Care manager email address

4. Do you need an interpreter?

Interpreter required Yes No

If yes, what language? Include sign language, if needed.

6. How do you want to complete the CANS assessment?

Assessment method Telehealth assessment In-person assessment at a place you choose

Email address to get the Zoom link

Requires Internet access and a computer, smartphone, or tablet with camera.

Street address

Apartment or unit

City

State

ZIP Code

Location phone number

Location notes

Include details about pets, parking, apartment building codes, and other information about accessing the chosen location. Do not include personal, medical, or other sensitive information. 150-character limit.

Next steps

Step 1: Request received

After you submit this form, a success page will display that tells you we received your request.

Step 2: Appointment confirmation

A CANS scheduler will email you within 2 business days to confirm your appointment or let you know the status of your request.

Step 3: Confirmation email

Once your appointment is scheduled, you and your care manager will get a confirmation email from Maximus with the appointment details.

Need help?

212-908-6671
Toll-free number: 844-916-7933

Monday-Friday, 8:30 am - 5:30 pm

www.opwddassessment.com

Privacy acknowledgment I understand that the information I provide will be used for scheduling purposes and stored in Maximus systems in accordance with applicable privacy and security requirements. Read our

Assessment assignment acknowledgment I confirm that the person is assigned to Maximus for assessment.

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