Electronic DSHS Forms

You may download some DSHS forms. These are provided only if a DSHS program requests forms to be available electronically for public use. DSHS forms are available for electronic completion in different software; however, all DSHS forms below are available as Adobe Acrobat PDF files. This means you can open, view, and print each form. To open, view, and print PDF forms, you need to download the free Adobe Acrobat Reader.

Additionally, you may download the free Shana Informed filler to electronically complete Shana forms below. On opening your first Shana form, you will be asked to enter a registration key. Please enter 32064015014070671 (you only need to enter this once).

We do our best to ensure the links below are accurate; but, if you find a link which does not work, please contact Forms and Records Management.

Choose search option and begin typing the form #
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Numbersort ascending Form Name File Format
27-161 Notice to Persons Creating a Mental Health Advance Directive
27-156 Notice and Consent of Communication via Text
27-147 Housing Modification Property Release Agreement
27-144 CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool
27-137 Applicant Request for a Copy of Background Check Results (Children's Administration)
27-132 Background Check Summary
27-131 Background Check Request Cover Sheet
27-130 Authorization for Alternate EBT Cardholder
27-129 Child Near Fatality Case Review Confidentiality Agreement
27-128 Child Fatality Case Review Confidentiality Agreement
27-127 Rights of Child and Youth in Foster Care
27-126 Local Indian Child Welfare Advisory Committee Confidentiality Agreement
27-124 Provider Owned Housing Memorandum of Understanding Residential Provider Attestation
27-123 Provider Owned Housing Memorandum of Understanding Renter Attestation
27-122 HCS / AAA / DDA Individual Provider Contractor Intake
27-121 Waiver of Right to Receive Written Information on Adoption Support Program Limitation
27-115 Privacy Complaint
27-113 Attestation of Individual Provider's Living Situation
27-111 Continuous Quality Improvement Confidentiality Agreement (Children's Administration)
27-110 Applicant Request for a Copy of Background Check Information
27-109 BCCU Applicant Affidavit
27-107 Post Placement Report (Children's Administration)
27-106 Family Participation Agreement (Children's Administration)
27-104 Interstate Compact On Placement of Children (ICPC) Closure Letter
27-100A DBHR Authorization to Release Information and Photographs (Division of Behavioral Health and Recovery)
27-096 Permission to Share Documents for Reimbursement of Medical Expenses
27-095 Court Report (Children's Administration)
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
27-093 School Notification (Children's Administration)
27-089 Fingerprint-Based Background Check Notice
27-082 Five Day Notice to Move (Children's Administration)
27-081 Employment and Day Program Services Providers: Mandatory Reporting of Abandonment, Abuse, Neglect, Exploitation, or Financial Exploitation of a Child or Vulnerable Adult (Developmental Disability Administration)
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
27-063 Voluntary Placement Services For Youth (Age 18-21)
27-059 Finger Print Appointment
27-057 Voluntary Placement Services Provider Referral Letter (DDA)
27-056 Dependent / Ward of the Court Verification
27-053 Paternity Information
27-051 DSHS / Union Contract Decision Process
27-043 Contractor Intake
23-041 Washington State Child Abuse and Neglect Founded Findings Request from Another State
23-037 Background Clearance Notification
23-036A Child Placing Agency Foster Home Licensing Investigation Interviews
23-036 Child Placing Agency Foster Home Licensing Investigation
23-035 CHINS/ARY Report to Juvenile Court
23-034 Alternative Living Financial Report
23-033 Child Abuse and Neglect Information Request
23-032 In-State Child Abuse and Neglect Founded Findings Request
23-027 90 Day Review Checklist For Social Workers Staffed Residential Facilities, Group Care Facilities and Child Foster Homes
21-060 Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment
21-059 Children's Staffed Residential Quality Assurance Assessment
20-289 ICJ (Interstate Compact for Juveniles) Transition Checklist (Juvenile Rehabilitation)
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program
20-271 JRA Integrated Treatment Assessment (Rehabilitation Administration) 
20-260 Request for Warrant Check on JR Youth (Juvenile Rehabilitation)
20-256 Integrated Treatment Plan (Juvenile Rehabilitation)
20-253 Polygraph Notification (Juvenile Rehabilitation)
20-250 Consent for Release to Parent/Guardian/Involved Individual (Juvenile Rehabilitation)
20-247 Youth Media Release (Juvenile Rehabilitation)
20-240 Administrative Reports of Incidents (Parole Programs) (Juvenile Rehabilitation)
20-238 Administrative Report of Incidents (Juvenile Rehabilitation)
20-236 Notification and Legal Requirements (Juvenile Rehabilitation)
20-235 SchoolNotification (Juvenile Rehabilitation)
20-234 Juvenile Rehabilitation Youth Complaint
20-230 Juvenile Volunteer Project Supervisor Agreement (JR Community Facility)
20-229B Conditions of Treatment Provider Agreement (Juvenile Rehabilitation)
20-229A Conditions of Employment Employer Agreement (JR Community Facility)
20-228A Conditions of School Involvement School Agreement (JR Community Facility)
20-228 Conditions of School Involvement School Agreement (JR Community Facility)
20-227 Wanted Person Notice of Cancellation (Juvenile Rehabilitation)
20-226 Claim for Damages (Juvenile Rehabilitation)
20-225 Claim for Facility Damages (Juvenile Rehabilitation)
20-223 Parent/Guardian Notification (Juvenile Rehabilitation)
20-222 Sexual Aggression Vulnerability Youth Assessment (Juvenile Rehabilitation)
20-220 Supervisory Case Review (Juvenile Rehabilitation)
20-219 Request for Exception to Standards (Juvenile Rehabilitation)
20-216 School Behavior Records Request (Juvenile Rehabilitation)
20-215 Law Enforcement Records Request (Juvenile Rehabilitation)
20-214 Youth Suicide Precaution Tracking (Juvenile Rehabilitation)
20-201 Authorized Leave Approval (Juvenile Rehabilitation)
20-199 Room and Isolation Confinement Record (Juvenile Rehabilitation)
20-198 Sentencing Worksheet (Juvenile Rehabilitation)
20-191 Youth Personal Property Transmittal (Juvenile Rehabilitation)
20-190 Personal Property Inventory (Juvenile Rehabilitation)
20-188 JR (Juvenile Rehabilitation) Authorized Leave Order
19-232A Academic Cost Continuation
19-232 Academic Cost
19-231C Program Billing Details Continuation
19-231B Program Billing Details
19-231A Individual Site Billing Details
19-228 Juvenile Accountability Incentive Block Grant (JAIBG) Progress Report
19-227 Juvenile Accountability Incentive Block Grant (JAIBG) Financial Report (JRA)
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
18-700 Direct Deposit Authorization
18-682 Detail Sheet – Uninsured Health Care Expenses
18-681 Request for Collection of Uninsured Health Care Expenses
18-627 SSP Client Overpayment Notice (State Supplementary Program)
18-607 Child Care Verification
18-555 Financial Information Sheet
18-551 School Statement
18-544 Transmittal of Resident Personal Funds
18-504 Financial Information Sheet Instructions
18-503 Financial Information Sheet
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
18-483 Employer Payment Identification Instructions
18-464 Introduction to New Hire Reporting
18-463 New Hire Reporting Methods and Instructions
18-433 Declaration of Support Payments (Division of Child Support)
18-400A Third Party Claim Checklist (Children's Administration)
18-400 Foster Parent Reimbursement Claim and Checklist (Children's Administration)
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
18-399 Social Service Incorrect Payment Computation
18-398A Vendor Overpayment Notice
18-398 Client Overpayment Notice
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
18-176A Address Release Information Letter
18-176 Address Release Information Letter
18-097 Statement of Resources and Expenses
18-078 Application for Nonassistance Support Enforcement Services
17-242 Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration)
17-238 ODHH Approved Sign Language Interpreter Complaints
17-234 Declaration of Commercial Purposes
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
17-227 DSHS / HCA Systems Access Request
17-226 AAA DSHS / HCS Systems Access Request
17-215 DSHS / CA Checklist: Subcontractors Approval Request (Children's Administration
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
17-208 PRISM Registration
17-194 Request for Mental Health Service Information
17-180 Personal Information Release (Economic Services Administration)
17-155 Sign Language Interpreter Registration
17-123A Request for Sign Language Interpreter
17-123 Spoken Language Interpreter Service Appointment Record
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
17-063 Authorization
17-041A Request for Children's Administration Records
17-041 Request for Records
17-011 Forms and Publications Request
16-237A ALTSA GovDelivery Communication Request (Aging and Long-Term Support Administration)
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
16-235 Photo Release
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-232 Medicaid Provider Profile Request
16-231 Permanency Planning Matrix
16-230 Children's Residential Services
16-229 Educational Resources for Youth in Foster Care Through DSHS in Washington State or a Tribal Child Welfare Agency
16-225 Respite Provider Checklist
16-221 Children's Respite in Licensed Staffed Residential/Foster Home Settings
16-220 SOLA Incident Report (DDA)
16-218 Intake Cover Letter to Tribes
16-217 Interstate Compact On Placement of Children (ICPC) Quarterly Supervision Report
16-213 Verification of Legal Status
16-211 DLR Agency Letter of Reference (Division of Licensed Resources)
16-209 Archived Records Memo for Adoption
16-205 Personal Emergency Plan Information
16-204 Emergency Evacuation Plan (Children's Administration)
16-203 SIS Rating Key
16-202A Plan of Correction (5-Day Investigation)
16-202 5-Day Investigation Report
16-200 Memo to Provider for Behavior Support, Counseling, and Consultation Services
16-199 New Case/Resource Manager Technology Training Checklist
16-198 Individual Provider Notification
16-197 Assisted Living Facility Policies and Procedures Attestation
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-194 DDA Specialty Training Sign-Up Sheet
16-193 Nurse Aide Registry Inquiry (ADSA)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
16-182 Guidelines for Completing the ICAP/SIB-R Adaptive Behavior Scale (Children's Administration)
16-181 A Guide to In-Home Relative Child Care
16-180 CCSP Rights and Responsibilities (Child Care Subsidy Programs)
16-179 Reference Cover Letter (Children's Administration)
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Long-Term Support Administration
16-107 Noncustodial Parent's Rights and Responsibilities
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
15-496 Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration)
15-495 Individual Habilitation Plan (IHP) (Developmental Disabilities Administration)
15-494 Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration)
15-493 PASRR Client Referral
15-492 Medicaid Transformation Project Demonstration Service Notice
15-491 Plan of Safe Care
15-490 Background Check Administrative Review for Contracts
15-481 CCRSS Complaint Investigation
15-480 PASRR Notice of Determination
15-479 Level 2 PASRR Supplemental Substance Use Disorder Questionnaire
15-478 Level 2 PASRR Follow-Up or Significant Change in Condition Psychiatric Evaluation Summary
15-474 Notification of Age 20 Eligibility Expiration
15-473 Notification of Age 18 Eligibility Expiration
15-472 After-the-Fact Contract Justification
15-471 CA / RCM Contract Request / Approval
15-470 DSHS / CA Regional Staff Contract Request / Approval
15-469 Pre-Contract Action Request (P-CAR)
15-468 Immediate Action Plan Compliance Agreement (Contracts)
15-467 Compliance Agreement
15-466 Contract Risk Assessment / Analysis
15-465 Monitoring Report for Compliance Action Notice
15-464 Compliance Agreement On-Site Review Final Report
15-463 Compliance Agreement Desk Review Final Report
15-462 Monitoring Review Report – On-Site Visit
15-461 Monitoring Review Report – Desk Review
15-460 Out of State Child Abuse and Neglect Check
15-458 Adult Family Home Notice of Transfer or Change
15-456 RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
15-455 Certificate of Exemption
15-454 Parent - Child Visit (PCV) Incident Report
15-452 Sibling Visit Report
15-451 Missed and No Show Report: Parent - Child Visit
15-450 Child Specific Caregiver Notification
15-449 Adult Family Home Disclosure of Charges Required by RCW 70.128.280
15-448 Visit Report: Parent - Child Visit
15-447 Exception to Rule (ETR) to Exempt Room Requirements (Home and Community Services)
15-446 Complaint Investigation
15-445 Follow-up / Monitoring Inspection
15-444 Re-Inspection
15-441 Team Coordinator (Assisted Living Facility)
15-440 Complaint Investigation (Assisted Living Facility)
15-439 Follow-up / Monitoring Inspection (Assisted Living Facility)
15-438 Inspection (Assisted Living Facility)
15-437 Staff Orientation Checklist
15-436 Request for Adult Family Home Application Fee Waiver
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration
15-434 On-Going Mental Health (OMH) Screening Report
15-433A Provisional Expedited Incomplete Application (Children's Administration)
15-433 Incomplete Application
15-432 Educational Liaison's Report to the Court
15-431 Extended Foster Care Services Voluntary Placement Agreement
15-430A Seasonal Child Care (SCC) Denial Notice
15-430 Seasonal Child Care (SCC) Client Termination Notice
15-428 Protective Action(s) Plan (Children's Administration)
15-425 Adoption Redaction Request (Children's Administration)
15-424 Staffed Residential Cost of Care Adjustment Request
15-422 No Paid Services Group
15-420 Request For ICF / IID or SONF Admission
15-419 Refusal of Services Statement
15-417 Transition Plan for Youth Exiting Care
15-412 Disability Verification for Youth Over Age 18
15-411 Licensing Waiver/Administrative Approval
15-402 Notice to Foreign Consulate of Child Protection Proceedings
15-398 Medically Intensive Children's Program (MICP) Application
15-389 Certified Community Residential Services and Support Application
15-388 Alternative Living Review and Evaluation
15-387 Children’s Respite Application
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA)
15-383 Functional Behavioral Assessment (FA)
15-382 Positive Behavior Support Plan (PBSP)
15-381 Respite Assessment Worksheet
15-380 Individual and Family Services Assessment Worksheet
15-379 Staff Add-on Request for Client Specific Need (DDA)
15-377 Education and Training Voucher (ETV) Program Dual Credit Application
15-376 Skin Observation Protocols
15-375 Home Study Referral for Contracted Services
15-372 Enumeration Referral
15-370 Education and Training Voucher (ETV) Program Payment Request
15-369 Educational and Training Voucher (ETV) Program Renewal Application
15-368 Educational and Training Voucher (ETV) Program Participation Agreement
15-367 Background Check Administrative Review
15-366 Change of Address
15-365 Community Protection Treatment Worksheet Quarterly Review
15-363B Provider Notification of Visit / Transport Schedule Initial Intake Screening Report
15-363 Visit Referral
15-362 Concurrent TANF Benefits / Family Reunification Notice of Removal from TANF Home (Children's Administration)
15-360 Residential Services Capacity Profile
15-359 Child's Physical Description
15-358 Client Referral Information
15-356 DDA Community Protection Program Chaperone Agreement
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
15-342 Notice of Exception to Rule Decision
15-331 Annual Assessment Checklist (Developmental Disability Administration)
15-324 Guardianship Approval Checklist
15-323 Checklist For Approval Long Term Care Agreement For Foster Parents or Relative Caregivers
15-322 Long Term Care Agreement For Foster Parents or Relative Caregivers
15-318 DDA Crisis Diversion Bed Referral and Intake Information
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
15-313 Caregiver's Report to the Court
15-309 Returning Child De-Briefing
15-308 Missing Child Staffing
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
15-300 Child Information and Placement Referral
15-295 Person Centered Service Plan Meeting Survey
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-290 Notification of Annual Assessment Review
15-286A Adult Child Reference Questionnaire (Children's Administration)
15-286 Reference Questionnaire
15-282A Request for Enrollment in Developmental Disabilities Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change from One DDA HCBS Waiver to Another
15-281 Placement Agreement (Children's Administration)
15-280 Unlicensed Caregiver Placement Checklist (Children's Administration)
15-276 Personal Information (Children's Administration)
15-274 Assistance Available Schedule (DDA)
15-268 CPT Case Presentation Summary
15-266 CPT Staffing Recommendations
15-260 Parent Information Sheet For Shared Planning Meetings and Staffings
15-259A Case Plan
15-259 Safety Plan
15-258 Safety Assessment
15-252 DRW Access Request Checklist
15-247D Child Care Subsidy Programs (CCSP) Income Eligibility Phase Out and Termination Plan
15-247C Child Care Subsidy Program (CCSP) Provider Payment Termination Notice
15-247A Child Care Subsidy Programs (CCSP) Denial Notice
15-247 Child Care Subsidy Programs (CCSP) Termination Notice
15-245 LEP Client Service Record (Limited English Proficient)
15-243 Social Services Case Reading Guide
15-215 AFH Quality Improvement Visit Assessment
15-209C Visit Plan
15-184 Volunteer Chore Service Referral
15-128 Verification of Indian Status: Foster Care and Adoptive Applicant
15-093 Interstate Compact on the Placement of Children Report on Child's Placement Date or Change of Placement - 100B
15-092 Interstate Compact On Placement of Children (ICPC) Placement Request
15-031 Notice of Action - Adult Residential Services
14-547 Continuing Care Retirement Community (CCRC) Registration Application
14-544 Continuing Education Summary for DVPT (Domestic Violence Perpetrator Treatment) Providers (Children's Administration)
14-543 Application for Renewal Program Certification (Children's Administration)
14-542 Application for New Program Certification (Children's Administration)
14-541 ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents)
14-540 Irrevocable Burial Fund Provision for SSI Related Healthcare
14-539 Revocable Burial Fund Provision for SSI Related Healthcare
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
14-534 SDCP Eligibility Checklist (Home and Community Services)
14-532 Authorized Representative
14-531 Education and Training Voucher (ETV) Program and Passport to College Promise Scholarship Application
14-530 Disability Review
14-529 Chemical Dependency Requirement
14-528 Chemical Dependency NonCooperation
14-527 Medical Care Services Case Plan
14-526 Chemical Dependency Treatment Verification Request
14-525 Incapacity Review for Medical Care Services
14-521 Your Rights (Home and Community Services)
14-520 Your DSHS Cash or Food Assistance Benefits
14-517 DSHS Letter Requesting Non Work SSN
14-515 Notice and Finding of Responsibility
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-513 Respite Care Provider Cover Letter
14-512 Application For Respite Provider Approval
14-510 Respite Provider Policy Agreement
14-505 Application for Deaf-Blind Communicator (DBC)
14-503 Interim Assistance Reimbursement Agreement Cover
14-502 SSI Hearing Denial
14-501 Community Resource Declaration
14-495 Naturalization Letter
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
14-492 Assessment Meeting Wrap-up
14-491 NSA Representative Checklist forDDA Review
14-489 SSIF Introduction Letter
14-485 GAIN-SS (Mental Health)
14-484 Nurse Delegation: Nursing Visit
14-479 DASA Target Data Element - Gain Short Screening Setup
14-478 Treatment Verification Request
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-474 Shared Planning Meeting
14-473 Inventory for Client and Agency Planning (ICAP) Letter
14-467 Mid-Certification Review
14-465 Sources For Eligibility Information (DDA)
14-463 Waiver Transportation Record (DDA)
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-459 Eligible Conditions Specific to Age and Type of Evidence (Developmental Disabilities Administration)
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
14-453 Protective Payee Decision
14-452 Financial Worksheet (Children's Administration)
14-449 Unmet Need Breakdown
14-446 Declaration of Financial Status Declaration of Financial Status for Adoption Support Application (Children's Administration)
14-444 Child Health and Education Tracking Screening Report (Children's Administration)
14-443 Financial / Social Services Communication
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
14-439 WASHCAP Application
14-438 Stop Work
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-435 Provider Employment Eligibility Verification (Children's Administration)
14-434 Title IV-E Requirements for Out of State Foster Care Payments (Children's Administration)
14-432 Direct Deposit Enrollment
14-431 Medical / Dental Services Authorization
14-427 Teen Parent Living Assessment
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
14-417A In-Home/Relative Pending Letter (Child Care Subsidy Program)
14-417 Child Care Subsidy Programs (CCSP) Application
14-416 Eligibility Review for Long Term Services and Supports
14-413A Level 2 Interrupted Evaluation
14-413 Level 2 PASRR Invalidation
14-402 Notice to Parents (WorkFirst)
14-401A Notification of Address Disclosure Request - Part 2
14-401 Notification of Address Disclosure Request - Part 1
14-381 WorkFirst Individual Responsibility Plan
14-349 Protective Payee Assessment
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-338 Level 2 PASRR Initial Psychiatric Evaluation Summary
14-332 Disability Assessment
14-319 Title IVE Initial Eligibility Determination for an Adoption Support Application (CA)
14-310 Client Status Change Report
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
14-299 Adult Assessment Referral (Economic Services Administration)
14-293 Title IVE Initial Eligibility Determinations: Income Calculation Worksheet (Children's Administration)
14-281 Source of Funds Application for Child in Placement
14-264 Application for Telecommunications Equipment
14-252 Employment Verification
14-245 Education List Checklist (Juvenile Rehabilitation)
14-238 Client Income Report
14-225 Acknowledgement of Services
14-224 Statement from Landlord/Manager
14-223 Statement from School
14-222 SUMMARY Statement of Collateral Information Summary
14-222 Statement of Collateral Information
14-162 Veteran's Referral
14-155 Senior Citizens Service Application
14-151 Request for DDA Eligibility Determination
14-144A Medical Disability Decision
14-118A ADATSA Incapacity Decision/Disposition
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-105 Interview Appointment for Applicant (Community Services Division)
14-084 Social Service Referral
14-078 Eligibility Review
14-076 Change of Circumstances
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-057D Child Support Referral Continuation
14-057B Noncustodial Parent Child Support Enforcement Application
14-057 Child Support Referral
14-050 Statement of Health, Education, and Employment
14-012 Consent
14-001 Application for Cash or Food Assistance
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
13-906 Therapy Assessment Bed Rails or Side Rails (Home and Community Services)
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
13-899 Review of Medical Evidence
13-893 Nurse Delegation: Request For Additional Units
13-865 Psychological/Psychiatric Evaluation
13-851C Psychoactive Medication Treatment Plan Annual Continuation of Medication
13-851A Psychoactive Medication Treatment Plan
13-851 Psychiatric Referral Summary
13-830 Admissions Review Team Checklist for Admission to an ICF/IID or SONF
13-784 Nursing Services Assessment
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
13-776 Nursing Services Referral (Home and Community Services)
13-738 DDA / CA Request to Cost Share
13-734 Documentation of First Use of Medicaid Benefits (DDA)
13-713 Fast Track Service Agreement
13-712 Personal Care Related to Diagnosed Psychiatric Condition
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
13-690 Medical Services Authorization (Juvenile Rehabilitation)
13-681 Nurse Delegation: Change in Medical Orders
13-680 Nurse Delegation: Rescinding Delegation
13-678B Nurse Delegation: Assumption of Delegation
13-678A Nurse Delegation: PRN Medication
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
13-645 Adult Family Home Injuries and Accidents Log
13-628 Involuntary Treatment Act Patient Claim Information
13-585A Range of Joint Motion Evaluation Chart
13-433 Transfer/Discharge Health Summary (Juvenile Rehabilitation)
13-041 Child’s Medical and Family Background Report
13-021 Physical Evaluation
13-001 Applicant Medical Report - Confidential
12-207 Application for Disaster Cash Assistance
12-206 Application for Disaster Food Benefits
12-195 Disqualification Consent Agreement
12-006 Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program
11-142 Service Delivery Outcome Plan: Pre-ETS IL Skills Training
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
11-132 90 Day Review (Division of Vocational Rehabilitation)
11-125 Service Delivery Outcome Plan: WBL - Experience C
11-124 Service Delivery Outcome Plan: WBL - Experience B
11-123 Service Delivery Outcome Plan: WBL - Experience A
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
11-117 Student Summary Report
11-116 Work-Based Learning Report
11-115 Workplace Readiness Report
11-114 Referral Contact Sheet
11-113 Pre-ETS (Pre-Employment Transition Services) Social Skills (Division of Vocational Rehabilitation)
11-112 Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation)
11-111 Pre-ETS (Pre-Employment Transition Services) Job Exploration (Division of Vocational Rehabilitation)
11-110 Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation)
11-107 Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation)
11-106 Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation)
11-105 PETS CCTS Quarterly Report
11-104 Highline Community College, PETS Student Summary Report
11-103 Highline Community College, PETS Phase 3.0 Summer Internship Report
11-102 Highline Community College, PETS Phase 2.0 Summer Career Readiness Academy (SCRA) Report
11-101 Highline Community College, PETS Phase 1.0 School-Based Job Clubs Report
11-100 Community Rehabilitation Program (CRP) Generic Update Report
11-098 Vocational Assessment Worksheet
11-097 Service Delivery Outcome Report (Independent Living Services - IL)
11-094 Large Print User Agreement (Large Print) (Office of the Deaf and Hard of Hearing)
11-094 User Agreement (Office of the Deaf and Hard of Hearing)
11-093 Outreach Attendance (Office of the Deaf and Hard of Hearing)
11-088 Interagency Agreement - DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
11-084 Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation)
11-080 Centers for Independent Living (CILs) Title VII, Part B Monthly Report
11-079 Centers for Independent Living (CILs) Title VII, Part B, Contract Annual Report
11-078 Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation)
11-072 DVR Internship Evaluation (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-068 DVR Internship Application (Division of Vocational Rehabilitation)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
11-066 Assistive Listening Device(s) (ALD) Sign-Out Register (Office of Deaf and Hard of Hearing)
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
11-055 Acknowledgement of My Responsibilities As The Employer of My Individual Providers
11-046 Work Experience (WEX) Agreement (Food Stamp Employment and Training)
11-045 Work Experience (WEX) Referral (Food Stamp Employment and Training)
11-034B Basic Food Eligibility Requirements: What You Need to Know
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
11-022 Application for Vocational Rehabilitation Services
11-019 Vocational Information (Division of Vocational Rehabilitation)
10-590 Physical Therapy Evaluation
10-589 Recreation Assessment
10-585 Adult Family Home Information Changes
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-583 DDA PASRR Cover Sheet
10-582 Notification of Age Twenty (20) Eligibility Review (Developmental Disabilities Administration)
10-581 Unlicensed Placement Application Checklist
10-580 Adult Day Services Referral
10-578 Licensing Application Checklist (Division of Licensed Resources)
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-574 Roads to Community Living (RCL) Person Centered Transition Planning
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-572 Respite Application for Overnight Planned Respite (OPRS), Emergent and/or Planned Short-Term Stay Services at an RHC
10-571 Overnight Planned Respite Services Individualized Agreement
10-570 Intake and Referral
10-569 Child Abuse and Neglect Medical Consult Referral
10-567 Contracted Health and Safety Visit Report
10-566 Contracted Health and Safety Visit Referral
10-565 Medical Exemption for Influenza Vaccination
10-547 Adoption Support Limitations Letter
10-546 Adoption Archive Request for Non-Identifying Information
10-545 Family Feedback Questionnaire
10-541 Comprehensive Review: DLR Foster Home File
10-540 Project SafeCare Monthly Summary
10-539 Reference Questionnaire for Parent Home Study
10-537 Interstate Compact On Placement of Children (ICPC) Parent Home Study Information
10-535 Enhanced Services Facility Application
10-532 Team Coordinator Survey
10-531 Session 3 Participatory Survey
10-530 Session 2 Participatory Survey
10-529 Session 1 Participatory Survey
10-528 Observational Surveys
10-527 Risk Assessment Survey
10-522 Comprehensive Review: Immediate Action Plan Compliance Agreement
10-521 Comprehensive Review: Compliance Agreement
10-520 Comprehensive Review Final Report
10-519 Incident Report Review
10-518 Foster Parent Interview
10-517 Staff Interview
10-516 Youth Interview
10-515 CA Worker Questionnaire
10-514 Comprehensive Review: Personnel Files
10-513 Comprehensive Review: DLR Client File
10-512 Comprehensive Review: BRS Contractor Client File
10-511 Comprehensive Review: DLR Program Review
10-510 Comprehensive Review: BRS / Contracts Program Review
10-509 Pediatric Symptoms Checklist (PSC-17)
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-507 Orientation Sign-In Sheet
10-506 Limitation Extension Request Checklist
10-505 Limitation Extension Task Explanation
10-504 Limitation Extension Request for Clients Under Age 21
10-503 Limitation Extension Evaluation
10-502 Family Plan for Change
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-500 Acknowledgement of Child(ren)’s Adoptive File Provided to Adoptive Family (Children's Administration)
10-499 Education Plan (Children's Administration)
10-498A Family Assessment Response (FAR) Closing Letter (Translated Survey Enclosed)
10-498 Family Assessment Response (FAR) Closing Letter (Children's Administration)
10-497 Continuous Quality Improvement (CQI) Action Plan
10-496 Family Assessment Response: Referral for Community Resources (Children's Administration)
10-492 Service Referral (Children's Administration)
10-491 Statement of Children’s Administration (CA) Worker
10-490 Child Specific Contract Rate Proposal
10-489 Confidential Health Information Consent Agreement
10-488 Extended Foster Care Program Consent
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-486 Assisted Living Facility Food Service Observations - Attachment P
10-485 Treehouse Education Advocacy Program Case Activity Report (Children's Administration)
10-484 Youth Run Prevention Plan (Children's Administration)
10-481 Health Action Plan (HAP)
10-480 Comprehensive Family Evaluation (Children's Administration)
10-479 Early Intervention Program (EIP) 90 Day Review (Children's Administration)
10-477 Adoption Support Program Application Checklist (Children's Administration)
10-475 Early Intervention Program (EIP) Exit Summary (Children's Administration)
10-474 FAR Family Assessment (Children's Administration)
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
10-470 Children's Intensive In-Home Behavioral Support (CIIBS) Service Request (Developmental Disabilities Administration)
10-468 HCS / AAA / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-464 FamLink Access Application and Agreement (Children's Administration)
10-463 FamLink Data Access Request / Change (Children's Administration)
10-462 User Application and Agreement (Children's Administration)
10-460 Treehouse Educational Advocacy Referral (Children's Administration)
10-459 Courtesy Supervision Referral
10-458 Home Study Referral Notice (Children's Administration)
10-456 Mental Health Treatment Options
10-455 Medical Log (Children's Administration)
10-454 Children's Administration Caregiver Authorization
10-453 Household Safety Inspection for Unlicensed Placements and Adoption Home Study Updates
10-450 Statement of Qualifications and Verification of Issues Discussed (Children's Administration)
10-448 Nurse Delegation Contract Monitoring Chart Audit
10-444 Relative Caregiver / Suitable Other Placement Fact Sheet and Home Study Checklist
10-443 Organizations: Subscription and Directory (Office of the Deaf and Hard of Hearing)
10-442 Goal Setting and Action Planning Worksheet
10-438 Long-Term Care Partnership (LTCP) Asset Designation
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-436 Foster Care License Renewal Notice
10-432 Extended Foster Care Program Participant Agreement
10-428 Caregiver Support Plan (Children's Administration)
10-427 School District Communication
10-426 Respite Care Applicant Approval Letter
10-425 Respite Provider Reference Questionnaire
10-424 Voluntary Participation Statement (Developmental Disability Administration)
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-419 Licensing and Safety Supervision Plan For Site Specific Conditions
10-418 Fostering Well-Being Care Coordination Referral
10-417 Adult Family Home Caregiver Experience Attestation (CEA) Form A for Applicants for Licensure
10-416 Foster Home Monitoring Visit
10-413 Application For Contract For Currently Licensed Boarding Home
10-412 Adult Family Home License Relinquishment Letter
10-411 Consumer Response: Do Not Hang Up Complaint
10-410 Adult Family Home License Application