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(desc) | Form Name | File Format | |
|---|---|---|---|
| 15-383 | Functional Behavioral Assessment (FA) | ||
| 15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | ||
| 15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | ||
| 15-388 | Alternative Living Certification Evaluation (Developmental Disabilities Administration) | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 15-398 | Medically Intensive Children's Program (MICP) Application | ||
| 15-419 | Refusal of Services Statement | ||
| 15-424 | Staffed Residential Cost of Care Adjustment Request | ||
| 15-435 | Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration | ||
| 15-436 | Request for Adult Family Home Application Fee Waiver | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) | ||
| 15-449 | Adult Family Home Disclosure of Charges Required by RCW 70.128.280 | ||
| 15-456 | RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 15-458 | Adult Family Home Notice of Transfer or Change | ||
| 15-492 | Medicaid Transformation Project Service Notice | ||
| 15-493 | PASRR Client Referral | ||
| 15-494 | Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (Developmental Disabilities Administration) | ||
| 15-501 | Service Request Contact Notice (Developmental Disabilities Administration) |
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| 15-512 | Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration) | ||
| 15-514 | Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration) | ||
| 15-515 | CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration) | ||
| 15-516 | Companion Home Quarterly Report (Developmental Disabilities Administration) | ||
| 15-517 | Application for Transition from Group Home to Group Training Home | ||
| 15-547 | Continuing Education Event Approval Application (Aging and Long-Term Support Administration) | ||
| 15-548 | Adult Family Home Administrator Training Instructor Application (Home and Community Services) |
