| Abuse & Neglect |
|---|
Adult Protective Services (APS)
- 032-02-0150-00-eng (PDF)
- APS Report (PDF)
- Appendix K (PDF)
- Assisted Living Facility Level of Care Worksheet (PDF)
- Assurance of Confidentiality (PDF)
- Compliance Form for Department Approved Provider (PDF)
- Consent to Exchange Information (PDF)
- Consent to Exchange Information (Spanish) (PDF)
- Eligibility Communication Document (PDF)
- Interagency Consent to Release Confidential Information for Drug and Alcohol Patients (PDF)
- Medicaid Funded Long-Term Care Service Authorization (PDF)
- Rights of Adults in Care (PDF)
- Tuberculosis Statement (PDF)
- UAI (Uniform Assessment Instrument) Plan of Care (PDF)
Child Protective Services (CPS)
- CPS Intake Tool (effective 8-1-2020) (PDF)
- Child Fatality Checklist (PDF)
- Family Service Agreement (English) - 4/19 (PDF)
- Family Service Agreement (Spanish) - 4/19 (PDF)
- Notification to Law Enforcement from CPS (PDF)
- Request for Search of the Child Protective Services (CPS) Central Registry (PDF)
- SDM Risk Assessment Tool (effective 4-15-2021) (PDF)
- SDM Safety Assessment Tool (effective 4-15-2021) (PDF)
- Safety Plan (Spanish effective 4-15-2021) (PDF)
- Safety Plan (effective 4-15-2021) (PDF)
- Service Application (PDF)
- Service Application (Spanish) (PDF)
- Sworn Statement of Affirmation for Foster and Adoptive Parents (PDF)
| Adoption & Foster Care |
|---|
Adoption
- AREVA Family Registration (PDF)
- Acknowledgement (PDF)
- Addendum Request to the Assistance Agreement (PDF)
- Addendum to the Adoption Assistance Agreement (PDF)
- Adoptee Application for Disclosure (PDF)
- Adoption Assistance Agreement (PDF)
- Adoption Assistance Screening Tool (PDF)
- Adoption inquiry
- Adoptive Parent Application for Disclosure (PDF)
- Adult Birth Sibling Application for Disclosure (PDF)
- Annual Affidavit for Adoption Assistance (PDF)
- Application for Assistance (PDF)
- Birth Parent Application for Disclosure (PDF)
- Certificate of Service (PDF)
- Certification (PDF)
- Child's Virginia Adoption Assistance Paper Case Record - Checklist (DOC)
- Commissioner's Confidential Report (DOC)
- Consent to Adoption (DOC)
- Entrustment Agreement for Permanent Surrender of a Child (PDF)
- Family Services Appeal Request (PDF)
- Family Services Notice of Action and Right to Appeal (PDF)
- Family Services Summary of Facts (PDF)
- Full Disclosure of Child Information (DOC)
- Home Study - Parental Placement Adoption (PDF)
- Information Sheet on the Virginia Adoption Assistance Program (PDF)
- Negotiation Report (PDF)
- Placement Agreement - Adoptive Home (PDF)
- Post-Adoption Contact & Communication Agreement (PDF)
- Referral for Negotiations (PDF)
- Relative Update to an Adoption Record (PDF)
- Report of Inquiries (DOC)
- Report of Investigation (DOC)
- Report of Investigation - Adult Adoption (PDF)
- Report of Investigation - Stepparent Adoption (PDF)
- Report of Suspected Violations (PDF)
- Report of Visitation (PDF)
- Supplemental Report of Investigation or Visitation (PDF)
- Virginia Birth Father Registry-Registration Form (PDF)
- Virginia Birth Father Registry-Request to Search (PDF)
- Virginia Worksheet for Assessing & Negotiating Adoption Assistance (DOC)
- Waiver of Full Name & Address in a Parental Placement Adoption - Suggested Format (PDF)
- Worksheet for Assessing and Negotiating Adoption Assistance- Spanish (PDF)
Foster Care (FC)
- Agreement to Resume Independent Living Services (DOC)
- Application to Resume Independent Living Services (DOC)
- Background Investigations (Web page)
- Child Health Information Form (DOC)
- Childrens Residential Facility with Code of Ethics and Mutual Responsibilities (PDF)
- Contingency Fund Application (PDF)
- Criminal Background Check Revised Non Conviction (DOC)
- Criminal Background Check Revised with Conviction (DOC)
- ETV Application (PDF)
- Family Services Appeal Request (PDF)
- Family Services Notice of Action and Right to Appeal (PDF)
- Family Services Summary of Facts (PDF)
- Financial Agreement for Local Department of Social Services Approved Providers (Foster Parents) (PDF)
- Foster Care Agreement: Code of Ethics and Mutual Responsibilities (PDF)
- Fostering Futures 90-Day Transition Plan (PDF)
- ILP 90 Day Transition Plan (PDF)
- ILP Transition to Independent Living Plan (PDF)
- Independent Living Transition Plan Instructions (PDF)
- LDSS Response to Request for VEMAT Review (DOC)
- Permanency Foster Care Agreement (DOC)
- Permanency Planning Indicator (PDF)
- Permanent Entrustment (PDF)
- Reasonable Candidacy Documentation Form (PDF)
- Relative Notification (DOC)
- Request for VEMAT Administration Due to Change in Child's Behaviors (PDF)
- Sworn Statement of Affirmation for Foster and Adoptive Parents, Adult Household Members (PDF)
- Temporary Entrustment Agreement (DOC)
- Title IV-E Foster Care and IV-E Medicaid Application (PDF)
- Title IV-E Foster Care and Medicaid Evaluation (PDF)
- Virginia Birth Father Registry: Registration Form (PDF)
- Virginia Birth Father Registry: Request to Search Registry (PDF)
- Virginia Enhanced Maintenance Assessment Tool (VEMAT) (PDF)
- Youth Rights Acknowledgement (PDF)
Interstate Compact on Adoption & Medical Assistance (ICAMA)
Interstate/Intercountry Placement of Children (ICPC)
Promoting Safe and Stable Families (PSSF)
-
Application for Funding
Virginia Birth Father Registry
| Adult & Child Care |
|---|
Adult Day Care Centers (ADCC)
-
New Applicants for Licensure
- New Applicant Memo (PDF)
- ADC Addendum (PDF)
- Annual Operating Budget (DOC)
- Annual Operating Budget (PDF)
- Initial Application (DOC)
- Initial Application (PDF)
- Instructions: Initial Application for Licensure (PDF)
- Personal Qualifying Information (PDF)
- Report of Environmental Sanitation Inspection (PDF)
- Request for Building Evaluation or Inspection (PDF)
- Staff Information Sheet (DOC)
- Staff Information Sheet (PDF)
Currently Licensed ADCC Providers
-
License Renewal
- ADCC Addendum (PDF)
- Instructions: Renewal Application for Licensure (PDF)
- Personal Qualifying Information (PDF)
- Renewal Application (PDF)
- Renewal Application (DOC)
- Request for Building Evaluation or Inspection (PDF)
- Staff Information Sheet (DOC)
- Staff Information Sheet (PDF)
All Other
- Annual Operating Statement & Working Budget (PDF)
- Annual Staff Training Record (DOC)
- Authorization to Release Confidential Information (PDF)
- Documentation of Health Care Supervision (DOC)
- Documentation of Health Care Supervision (PDF)
- Documentation of Physician's Oral Order for PRN Medication (PDF)
- Fire and Emergency Evacuation Drills (DOC)
- Fire and Emergency Evacuation Drills (PDF)
- Medication Administration Record (PDF)
- Participant Agreement (DOC)
- Participant Assessment (PDF)
- Participant Assessment (DOC)
- Participant Physical Exam (DOC)
- Participant Physical Exam (PDF)
- Participant Plan of Care (DOC)
- Participant Plan of Care (PDF)
- Participant Rights and Responsibilities (DOC)
- Participant Rights and Responsibilities (PDF)
- Staff Orientation and Initial Training (DOC)
- Sworn Statement or Affirmation for Adult Facility Employees (PDF)
- VA TB Risk Assessment for Over Age Six User Guide - 2023 (PDF)
Assisted Living Facilities (ALF)
-
New Applicants for Licensure
- New Applicant Memo (PDF)
- ALF Addendum (PDF)
- Annual Operating Budget (DOC)
- Annual Operating Budget (PDF)
- Initial Application (DOC)
- Initial Application (PDF)
- Instructions: Initial Application for Licensure (PDF)
- Personal Qualifying Information (PDF)
- Report of Environmental Sanitation Inspection (PDF)
- Request for Building Evacuation or Inspection (PDF)
- Staff Information Sheet (DOC)
- Staff Information Sheet (PDF)
Currently Licensed Providers
- Approval for Placement in Special Care Unit (PDF)
- Assessment of Serious Cognitive Impairment (PDF)
- Authorization for Release of Confidential Information (PDF)
- Auxiliary Grant Program Provider/DSS Communication Form (PDF)
- Auxiliary Grant Program Provider/DSS Communication Form (DOC)
- Department Approved Educational Program for Geriatric Assistant or Home Health Aide or for Nurse Aide (Not Covered Under 22 VAC 40-73-200 C 2) (PDF)
- Discharge Notification and Statement (PDF)
- Disclosure Statement (DOC)
- Disclosure Statement (PDF)
- Disclosure Statement - Effective 01/23/2025 (DOC)
- Disclosure Statement - Effective 01/23/2025 (PDF)
- Documentation of Physicians or Other Prescribers Oral Order for PRN (as needed) Medication (PDF)
- Individualized Service Plan (PDF)
- Liability Insurance Statement - Effective 01/23/2025 (DOC)
- Liability Insurance Statement - Effective 01/23/2025 (PDF)
- Medication Administration Record (DOC)
- Medication Administration Record (PDF)
- Mental Health Screening Determination Form (PDF)
- Non-Availability of Recommended Mental Health Services Form (PDF)
- Record of Initial ALF Staff Training (DOC)
- Record of Initial ALF Staff Training (PDF)
- Record of On-Site Health Care Oversight (DOC)
- Record of On-Site Health Care Oversight (PDF)
- Record of On-Site Health Care Oversight Additional Requirements for Restrained Residents (PDF)
- Record of Required Fire and Emergency Evacuation Drills (PDF)
- Record of Restraint Usage (PDF)
- Record of Staff Training and Education Following Employment (PDF)
- Report of Environmental Sanitation Inspection (PDF)
- Report of Resident Physical Examination (PDF)
- Resident Personal/Social Data (PDF)
- Resident Agreement (DOC)
- Resident Agreement (PDF)
- Resident Agreement - Effective 01/23/2025 (DOC)
- Resident Agreement - Effective 01/23/2025 (PDF)
- Review of Appropriateness of Continued Residence in Special Care Unit (PDF)
- Rights and Responsibilities of Residents of ALFs (DOC)
- Rights and Responsibilities of Residents of ALFs (PDF)
- Staff Record (PDF)
- Sworn Statement or Affirmation for Adult Facility Employees (PDF)
- Sworn Statement or Affirmation - Applicants for ALF Licensure (PDF)
- UAI (Uniform Assessment Instrument) Private Pay (PDF)
- VA TB Risk Assessment for Over Age Six User Guide - 2023 (PDF)
- VDSS Infection Prevention and Control Policies and Procedures Manual Template (DOC)
Currently Licensed Providers - License Renewal
- ALF Addendum (PDF)
- Instructions: Renewal Application for Licensure (PDF)
- Personal Quailfying Information (PDF)
- Renewal Application (PDF)
- Renewal Application (DOC)
- Request for Building Evaluation or Inspection (PDF)
- Staff Information Sheet (DOC)
- Staff Information Sheet (PDF)
Child Care Provider Scholarship Program
Child Placing Agencies (CPA) - Licensed
-
Background Investigations - Licensed CPA Employees
- Request for Search of the Child Protective Services (CPS) Central Registry (PDF)
- Sworn Statement or Affirmation for Child-Placing Agencies (PDF)
Background Investigations - Foster & Adoptive Homes
- Authority for Release of Information (PDF)
- Fingerprint Card Template (PDF)
- Request for Criminal Background Investigation (DOC)
- Request for Criminal Background Investigation (PDF)
- Request for Search of the Child Protective Services (CPS) Central Registry (PDF)
- Request to Discontinue Reprints (DOC)
- Request to Discontinue Reprints (PDF)
- Sworn Statement or Affirmation for Foster Homes, Adoptive Parents, Adult Household Members (PDF)
New Applicants for Licensure
- Annual Operating Budget (DOC)
- Annual Operating Budget (PDF)
- CPA Initial Application (PDF)
Currently Licensed CPA's
-
License Renewal
- CPA Renewal Application (PDF)
- Staff Information (PDF)
All Other
- Certificate of Approval (DOC)
- Certificate of Approval (PDF)
- Children's Dental Examination (PDF)
- Conducting a Name-Based Check of the National Criminal Database (PDF)
- Criminal Background Check Non Conviction (PDF)
- Criminal Background Check Revised With Conviction (PDF)
- Expedited Enrollment of Child Placed in Foster Care (PDF)
- Foster Care Agreement: Code of Ethics & Mutual Responsibilities (PDF)
- LCPA Provider Matrix (XLS)
- License Modification Request for Facility Change of Location (PDF)
- Mutual Family Assessment Model Form (DOC)
- Request for Search of the Child Protective Services (CPS) Central Registry (PDF)
- Sworn Statement or Affirmation for Child-Placing Agencies (PDF)
- Sworn Statement or Affirmation for Foster Homes, Adoptive Parents, Adult Household Members (PDF)
Children's Residential Facilities (CRF)
-
CRF - Background Investigations
- Fingerprint Card Template (PDF)
- Request for Search of the Child Protective Services (CPS) Central Registry (PDF)
- Sworn Statement or Affirmation for Children's Residential Facilities (PDF)
CRF - License Renewal
- VDSS CRF Renewal App for Conditional License (PDF)
- CRF Renewal Application (PDF)
- Staff Information (PDF)
CRF - All Other
- CRF Employee Matrix (XLS)
- Children's Residential Facilities Agreement: Code of Ethics & Mutual Responsibilities (PDF)
- Children's Residential Facilities Contact with Local Zoning Administrator (PDF)
- Discharge Information Provided to Resident's Legal Guardian (PDF)
- Discharge Summary (PDF)
- Documentation of Health Care Appointments (PDF)
- Face Sheet (PDF)
- Facility Self Report (PDF)
- Individual Service Plan (ISP) (DOC)
- Individual Service Plan (ISP) (PDF)
- Initial Objectives & Strategies (PDF)
- License Modification Request for Facility Change of Location (PDF)
- Monthly Evacuation Drill (PDF)
- Personnel Record Review Compliance Format for Children's Residential Facilities (PDF)
- Policy Checklist (PDF)
- Quarterly Progress Report (PDF)
- Reference Sheet for Each Owner/Operator Board Officers (PDF)
- Report of Environmental Sanitation Inspection (PDF)
- Request for Search of the Child Protective Services (CPS) Central Registry (PDF)
- Resident Records Review (XLS)
- Residential Environment Compliance (PDF)
