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(asc) Form Name File Format
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services)
10-613 Community Residential Services and Supports (CCRSS) Certification Evaluation Client Supports Observation (Residential Care Services)
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-605 ICF / IID Information Changes (Residential Care Services)
10-604 Supported Living Information Changes (Residential Care Services)
10-603 Nursing Home Information Changes
10-602 Enhanced Services Facility Information Changes
10-601 Assisted Living Facility Information Changes
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-591 Assisted Living Facility License Application
10-585 Adult Family Home Information Changes
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-583 DDA PASRR Cover Sheet
10-580 Adult Day Services Referral
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-574C Transitional Care Planning Tracking: Part C. Post Move and Stabilization (Developmental Disabilities Administration)
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-574A Transitional Care Planning Tracking: Part A. Transition Preparation (Developmental Disabilities Administration)
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-571 Overnight Planned Respite Services Individualized Agreement
10-570 Intake and Referral
10-535 Enhanced Services Facility Application
10-509 Pediatric Symptoms Checklist (PSC-17)
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-506 Limitation Extension Request Checklist