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(asc) Form Name File Format
10-505 Limitation Extension Task Explanation
10-504 Limitation Extension Request for Clients Under Age 21
10-503 Limitation Extension Evaluation
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-489 Confidential Health Information Consent Agreement
10-488 Extended Foster Care Program Consent
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-481 Health Action Plan (HAP)
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-442 Goal Setting and Action Planning Worksheet
10-438 Long-Term Care Partnership (LTCP) Asset Designation
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-427 School District Communication
10-424 Voluntary Participation Statement (Developmental Disability Administration)
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-417 Adult Family Home Caregiver Experience Attestation (CEA)
10-415 Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance)
10-413 Application For Contract For Currently Licensed Assisted Living Facility
10-412 Adult Family Home License Relinquishment Letter
10-403 Residential Services Providers and County and Count-Contracted Providers (Developmental Disabilities Administration (DDA): Mandatory Reporting of Abuse, Neglect, Exploitation, or Abandonment of a Child or Vulnerable Adult