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(asc) File Format
16-246 Your rights as a client of the Developmental Disabilities Administration
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-247 Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA
14-521 Your Rights (Home and Community Services)
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
16-279 Your Responsibility for Participation Towards Costs of Care at a Youth Transitional Care Facility (Developmental Disabilities Administration)
14-520 Your DSHS Cash or Food Assistance Benefits
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-381 WorkFirst Individual Responsibility Plan
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
13-928 Withdrawal of Petition for Conditional Release or Unconditional Release (Behavioral Health Administration)
13-919 Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration)
20-334 Washington State Learning Center (LC) New Course Request (Division of Developmental Disabilities)
14-439 Washington State Combined Application Program (WASHCAP) Application
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
14-463 Waiver Transportation Record (DDA)
09-508 Waiver of Statute of Limitations
12-212 Waiver of Administrative Disqualification Hearing (Community Services Division)
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
15-184 Volunteer Chore Service Referral
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
10-424 Voluntary Participation Statement (Developmental Disability Administration)
11-098 Vocational Assessment Worksheet
16-213 Verification of Legal Status