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.

Choose search option and begin typing the form #
Keyword Search
Number Form Name(desc) File Format
16-303 Recommended Diversion Plan (Office of Forensic Mental Health)
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
15-419 Refusal of Services Statement
06-200 Registered Nurse (RN) Delegation Billing
03-077 Release of All Claims
27-176 Release of Liability (Developmental Disabilities Administration)
17-297 Removal and Transport Directive (Behavioral Health Administration)
03-391 Report of Possible Client Assault
02-556 Request and Consent for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
15-436 Request for Adult Family Home Application Fee Waiver
10-238 Request for an Administrative Hearing (Residential Care Services)
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
18-681 Request for Collection of Uninsured Health Care Expenses
09-520 Request for Conference Board
14-151 Request for DDA Eligibility Determination
13-925 Request for Formulary Admission or Deletion (Behavioral Health Administration)
05-013 Request for Hearing
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
17-194 Request for Mental Health Service Information
17-041 Request for Records
10-709 Request for Residential Habilitation for Dependent Youth Services (Developmental Disabilities Administration)
11-192 Request to Provide CRP-IL Services and Background Check: Create Account (Division of Vocational Rehabilitation)
11-193 Request to Provide CRP-IL Services and Background Check: Update Account (Division of Vocational Rehabilitation)
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
16-302 Residency Agreement Language (Home and Community Living Administration)