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(desc) Form Name File Format
10-427 School District Communication
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-438 Long-Term Care Partnership (LTCP) Asset Designation
10-442 Goal Setting and Action Planning Worksheet
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-481 Health Action Plan (HAP)
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-488 Extended Foster Care Program Consent
10-489 Confidential Health Information Consent Agreement
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-503 Limitation Extension Evaluation
10-504 Limitation Extension Request for Clients Under Age 21
10-505 Limitation Extension Task Explanation
10-506 Limitation Extension Request Checklist
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-509 Pediatric Symptoms Checklist (PSC-17)
10-535 Enhanced Services Facility Application
10-570 Intake and Referral
10-571 Overnight Planned Respite Services Individualized Agreement
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-574A Transitional Care Planning Tracking: Part A. Transition Preparation (Developmental Disabilities Administration)