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.

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Number Form Name(desc) File Format
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
13-925 Request for Formulary Admission or Deletion (Behavioral Health Administration)
05-013 Request for Hearing
10-673 Request for ICF/IID or SONF Services at an RHC Administration Application
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
15-494 Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (Developmental Disabilities Administration)
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
17-296 Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration)
17-295 Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration)
10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration)
15-564 Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration)
15-360 Residential Services Capacity Profile
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
11-130 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
15-381 Respite Assessment Worksheet
13-899 Review of Medical Evidence
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
10-389 Room List For Assisted Living Facilities (ALF)
18-551 School Statement
07-098 Self Employment Monthly Sales and Expense Worksheet
14-155 Senior Citizens Service Application