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 | |
|---|---|---|---|
| 15-493 | PASRR Client Referral | ||
| 15-492 | Medicaid Transformation Project Service Notice | ||
| 15-458 | Adult Family Home Notice of Transfer or Change | ||
| 15-456 | RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 15-449 | Adult Family Home Disclosure of Charges Required by RCW 70.128.280 | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) | ||
| 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 | ||
| 15-424 | Staffed Residential Cost of Care Adjustment Request | ||
| 15-419 | Refusal of Services Statement | ||
| 15-398 | Medically Intensive Children's Program (MICP) Application | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 15-388 | Alternative Living Certification Evaluation (Developmental Disabilities Administration) | ||
| 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)) | ||
| 15-376 | Skin Observation Protocols | ||
| 15-366 | Change of Address | ||
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
| 15-360 | Residential Services Capacity Profile | ||
| 15-358 | Client Referral Summary (Developmental Disabilities Administration) |
