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(asc) | Form Name | File Format | |
|---|---|---|---|
| 15-424 | Staffed Residential Cost of Care Adjustment Request | ||
| 15-422 | No Paid Services Group |
|
|
| 15-419 | Refusal of Services Statement | ||
| 15-398 | Medically Intensive Children's Program (MICP) Application | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 15-388 | Alternative Living Certification Evaluation (Developmental Disabilities Administration) | ||
| 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 (Developmental Disabilities Administration) | ||
| 15-379 | Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration)) | ||
| 15-376 | Skin Observation Protocols | ||
| 15-366 | Change of Address | ||
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
| 15-360 | Residential Services Capacity Profile | ||
| 15-358 | Client Referral Summary (Developmental Disabilities Administration) | ||
| 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) | ||
| 15-318 | DDA Crisis Diversion Bed Referral and Intake Information | ||
| 15-314 | Client Necessary Supplemental Accommodation Representative Requirement Checklist |
