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Hcs intake and referral

Dshs intake form 2026

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4.8 out of 5

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The document provides intake instructions for Individual Providers (IPs) contracted with the Department of Social and Health Services (DSHS) in Washington State. It outlines the requirements for completing the Contractor Intake form, including personal 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 DSHS clients and must be submitted to the appropriate agency (HCS, AAA, or DDA) before any contract can be offered.

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Click ‘Get Form’ to open the dshs intake form in the editor.
Begin with Part A, where you will enter your Contractor Information. Fill in your name as it appears on your Social Security card, along with your gender, birth date, and contact details.
Provide identification details by selecting an unexpired picture ID type and entering your Social Security number. Ensure that the names match appropriately.
In the Specific Client Information section, indicate if you are providing services to a specific individual and state your relationship to them if applicable.
Complete the Suitability section by answering questions regarding any past contract terminations or criminal offenses. Attach additional explanations if necessary.
If applicable, fill out Part B regarding State Employee Information and ensure all required signatures are provided at the end of each part.

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

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