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HealthVine OhioRISE CANS (Child and Adolescent Needs and Strengths) Referral Form

Use this form to refer a youth for a CANS assessment to determine OhioRISE eligibility.

Information of individual filling out form

Information of individual who needs the CANS assessment

Note: The individual must be under 21 years old to receive a CANS assessment to determine OhioRISE eligibility.