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 | Form Name(desc) | File Format | |
|---|---|---|---|
| 15-579 | Enhanced Services Facility (ESF) Staff and Administrative Record Review | ||
| 15-585 | Enhanced Services Facility (ESF) Staff Schedule Worksheet (Residential Care Services) | ||
| 15-585B | Enhanced Services Facility (ESF) Staff Schedule Worksheet: 12-hour Shift (Residential Care Services) | ||
| 15-585A | Enhanced Services Facility (ESF) Staff Schedule Worksheet: 8-hour Shift (Residential Care Services) | ||
| 10-602 | Enhanced Services Facility Information Changes | ||
| 10-662 | Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 03-374D | ESA Non-Dislcosure of Confidential Information Agreement - Non Employee | ||
| 14-454 | Estate Recovery: Repaying the State for Medical and Long Term Services and Supports |
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| 07-107 | Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration) | ||
| 16-274 | Exhibit B: School-to-Work County Mentorship Program Monthly Tracking and Reporting (Division of Vocational Rehabilitation) | ||
| 15-554 | Facility Instructor Application (Home and Community Services) | ||
| 20-273 | Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program | ||
| 18-555 | Financial Information Sheet | ||
| 06-186 | Financial Solvency Information (Aging and Long-Term Support Administration) | ||
| 14-068 | Financial Statement (Division of Vocational Rehabilitation) |
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| 16-253 | For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services) | ||
| 16-255 | For Field Use Only: Sex Offender Notification to Facility (Home and Community Services) | ||
| 13-926 | Forensic (6358) Consultation (Behavioral Health Administration) | ||
| 11-152 | Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services) | ||
| 17-011 | Forms and Publications Request | ||
| 15-383 | Functional Behavioral Assessment (FA) | ||
| 10-442 | Goal Setting and Action Planning Worksheet | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 10-681 | Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 16-182 | Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration) |
