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.
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.
| Number(desc) | Form Name | File Format | |
|---|---|---|---|
| 01-210 | Transmittal of Client Funds from the Protective Payee | ||
| 02-714A | DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services) | ||
| 03-389A | Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790) | ||
| 10-269A | Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration) | ||
| 10-351 | Disclosure of Services Required by RCW 18.20.300 | ||
| 10-362 | Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D | ||
| 10-362A | Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D | ||
| 10-423 | Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services | ||
| 10-504 | Limitation Extension Request for Clients Under Age 21 | ||
| 10-508 | Adult Family Home Disclosure of Services Required by RCW 70.128.280 | ||
| 10-509 | Pediatric Symptoms Checklist (PSC-17) | ||
| 10-708 | Planning for Youth Aged 18-21 Receiving RHDY Services (Developmental Disabilities Administration) | ||
| 14-223 | Statement from School | ||
| 14-224 | Statement from Landlord/Manager |
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| 14-401 | Notification of Address Disclosure Request - Part 1 | ||
| 15-449 | Adult Family Home Disclosure of Charges Required by RCW 70.128.280 | ||
| 15-517 | Application for Transition from Group Home to Group Training Home | ||
| 15-574 | Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection | ||
| 15-585B | Enhanced Services Facility (ESF) Staff Schedule Worksheet: 12-hour Shift (Residential Care Services) | ||
| 15-593 | 21-Day Competency Check Request (Behavioral Health Administration) | ||
| 16-275 | Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services) | ||
| 27-063 | Out-of-Home Services Agreement for Youth (Age 18-21) (Developmental Disabilities Administration) | ||
| 27-247 | Residential Habilitation for Dependent Agreement for Youth (Age 18-20) (Developmental Disabilities Administration) |
