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 | |
|---|---|---|---|
| 15-436 | Request for Adult Family Home Application Fee Waiver | ||
| 15-435 | Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration | ||
| 15-429A | Notice of Decision on Request for School Break Personal Care Exception to Rule | ||
| 15-424 | Staffed Residential Cost of Care Adjustment Request | ||
| 15-419 | Refusal of Services Statement | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial 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)) | ||
| 15-366 | Change of Address | ||
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
| 15-360 | Residential Services Capacity Profile | ||
| 15-342 | Notice of Exception to Rule Decision | ||
| 15-318 | DDA Crisis Diversion Bed Referral and Intake Information | ||
| 15-295 | Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration) | ||
| 15-291 | Person Centered Service Planning and Annual Assessment Meeting |
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| 15-290 | Notification of Annual Assessment Review and Person Centered Services Planning Meeting | ||
| 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 | ||
| 15-184 | Volunteer Chore Service Referral | ||
| 15-031 | Nursing Facility Notice of Action | ||
| 14-553 | High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration) |
