• 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

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  • Child information

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  • Caregiver information

  • DFPS Worker information

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  • 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.

  • Clear
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  • Should be Empty: