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Hcs intake and referral

Dshs intake form 2025

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The document provides intake instructions for Individual Provider Contractors working with the Home and Community Services (HCS), Area Agency on Aging (AAA), and Developmental Disabilities Administration (DDA) in Washington State. It outlines the requirements for completing the Contractor Intake form, including necessary identification, client information, suitability checks, and ethics certification for current or former state employees. The form is mandatory for individuals providing personal care or respite care to clients under DSHS.

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Click ‘Get Form’ to open the dshs intake form in the editor.
Begin with Part A, where you will provide your Contractor Information. Fill in your name as it appears on your Social Security card, along with your gender, birth date, and contact details.
In the Specific Client Information section, if applicable, enter the name of the client you will be serving and your relationship to them.
Complete the Suitability section by answering questions regarding any past suspensions or debarments. If applicable, attach additional explanations as needed.
Proceed to Part B for State Employee Information. Answer whether you are a current or former Washington State employee and provide termination dates if necessary.
If required, complete Part C for Ethics Certification by confirming that there is no conflict of interest with your state employment.
Finally, review all sections for accuracy and sign the form before submitting it through our platform.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (191 Votes)
2015	4 Satisfied (26 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I contact DSHS Washington State?

Services are available at your local Community Services Office and by phone through the Customer Service Contact Center at 877-501-2233: TTY/TDD users dial 1-800-833-6384 for Washington Relay Service. Complete interviews for cash or food (application/eligibility review/mid-certification review).

What is the best time to call DSHS?

The best time to call is before 11 a.m. The busiest time to call is 11 a.m. to 2 p.m. We can determine your eligibility for all of our programs in one interview. How often can I get this help? This program is available to households for only one month in a 12-month period for each specified state of emergency.

What is the monthly income limit for food stamps in Washington?

How do I create an online intake form?

Create a client intake form using Google Forms. In Google Forms, click the plus sign. Click the Untitled form header box. Enter a name and description for the form. Click the Untitled Question box. Type What is your name? Click the dropdown menu to choose the type of answer field.

What is the phone number for Washington DSHS customer service?

Email: apscentralintake@dshs.wa.gov. Make a report online.

home and community services intake and referral

Dshs intake form pdf Dshs intake form online DSHS forms DSHS assessment Forms DSHS release of Information form DSHS stop work form DSHS application form DSHS forms PDF

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What is the DSHS stop work form for Washington state?

Stop Work Questionnaire (form 14-438) This form is used when you stop work or self employment. The form should be signed by you but must be completed by your employer. Your employer can also complete this form On-Line.

Dshs intake form 2025

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Complete this form in 5 minutes or less

Got questions?

How do I contact DSHS Washington State?

What is the best time to call DSHS?

What is the monthly income limit for food stamps in Washington?

How do I create an online intake form?

What is the phone number for Washington DSHS customer service?

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What is the DSHS stop work form for Washington state?

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