CATCH IT EARLY, SUPPORT IT BETTER:
A PRIMARY CARE PROVIDER'S INTRODUCTION TO THE CANS ASSESSMENT
Taking Place on 5/11/2026 from 12:30 – 2:00PM MT
Some Quick Questions
This brief survey helps us understand your current familiarity with Youth Empowerment Services
(YES) so we can tailor today’s training to best support school teams. Responses are used only
for training improvement.
Will you be attending:
In Person
Virtually via Zoom
Do you need any accommodations to fully participate in this training?
Is there a specific question you hope gets answered?
What best describes your role?
Pediatrician / Medical Provider
Mental Health Therapist/Counselor
Behavioral Interventionist
Peer Support Specialist
Case Manager / Care Coordinator
Social Worker
Community-Based Provider
Other
If you answered other above:
How frequently do you work directly with families or youth with serious emotional
disturbance?
Daily
Weekly
Occasionally
Rarely
In your work, families typically participate as:
Decision-makers
Collaborative partners
Contributors of information
Primarily recipients of services
It varies widely
Prior to today, how familiar were you with family-driven or youth-guided care
principles?
Very familiar
Somewhat familiar
Limited familiarity
Not familiar
How did you hear about this training?
Social Media
IPUL's Website
A Flyer
Liberty Healthcare
Other
Information About You
Are you a:
Parent
Professional
First Name:
Last Name:
Demographics:
Please select...
White or Caucasian
Black or African American
Asian
Pacific Islander
American Indian or Alaskan Native
Other
Unknown
Ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Other
Phone Number:
Email Address:
Join Mailing List
If you would like to be on IPUL's mailing list check this box.
Mailing Address
Mailing City
Mailing State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
This address is my
Home
Work
Professional Information
Organization Name:
My Title:
Phone Number:
Only if different from above
Email Address:
Only if different from above
Information About Your Child
Please only enter information for an individual child, you will be able to add more children below.
Child's First Name:
Child's Last Name:
Child's Gender:
Female
Male
Child's Birthdate:
Child's Demographics:
Please select...
White or Caucasian
Black or African American
Asian
Pacific Islander
American Indian or Alaska Native
Other
Unknown
Child's Ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Other
Child's Diagnosis:
Do You Have Another Child to Enter?
Yes
No
Information About Your Child (2)
Please only enter information for an individual child, you will be able to add more children below.
Child 2's First Name:
Child 2's Last Name:
Child 2's Gender:
Female
Male
Child 2's Birthdate:
Child 2's Demographics:
Please select...
White or Caucasian
Black or African American
Asian
Pacific Islander
American Indian or Alaska Native
Other
Unknown
Child 2's Ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Other
Child 2's Diagnosis:
Do You Have Another Child to Enter?
Yes
No
Information About Your Child (3)
Please only enter information for an individual child, you will be able to add more children below.
Child 3's First Name:
Child 3's Last Name:
Child 3's Gender:
Female
Male
Child 3's Birthdate:
Child 3's Demographics:
Please select...
White or Caucasian
Black or African American
Asian
Pacific Islander
American Indian or Alaska Native
Other
Unknown
Child 3's Ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Other
Child 3's Diagnosis:
If you have more than three children that you need assistance with, our Parent Education Coordinator will take your information directly.
Training Information
Incredibly Important Back End Stuff
(Hidden from person filling form, but
needs to be set up when building the registration or everything will be for naught and you will spend several days trying to fix your data WITH WOE IN YOUR HEART AND A POX UPON YOUR HOUSE)
Funding Source
separate with semicolon and put in
Default Value
under
Options
EXAMPLE
:
MCHB F2FHIC; PTI
(THESE NEED TO MATCH SALESFORCE OR PAIN WILL RESULT)