Forms Contract All | Expand All 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) Important Information ICAMA Professionals (DOC) Important Information ICAMA Professionals (PDF) Information exchange (Cases opened with ICAMA) - 032-02-0450-02-eng (DOC) Information exchange (Cases opened with ICAMA) - 032-02-0450-02-eng (PDF) Interstate/Intercountry Placement of Children (ICPC) Interstate Compact Placement Request 100A (PDF) Interstate Compact Report on Child's Placement Status 100B (PDF) Promoting Safe and Stable Families (PSSF) Application for Funding FY 2022 Quarterly and Yearly Report Template (XLS) PSSF COVID First Report (XLS) PSSF COVID Funding Application (XLS) SFY 2022 PSSF Renewal Application (XLS) SFY 2023 PSSF Renewal Application (XLS) SFY 2023 Quarterly and Yearly Report Template (XLS) 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 Schlarship Information Sheet-12-2015 (PDF) 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) Assistance Adult Services (AS) Auxiliary Grants (AG) Application for Benefits (PDF) Auxiliary Grant Certification Form FY19 (PDF) Auxiliary Grant Provider Agreement (PDF) Notification of Change (DOC) Provider/DSS Communication Form (PDF) Renewal Application for Auxiliary Grant (AG) (PDF) Request for Appeal (PDF) Child Care Assistance Child Care Providers Parents & Guardians Energy Assistance Fuel Assistance Fuel Assistance Application (English) (PDF) Fuel Assistance Application (Spanish) (PDF) Crisis Assistance Crisis Assistance Application (PDF) Crisis Assistance Application (Spanish) (PDF) Cooling Assistance Cooling Assistance Application (PDF) Cooling Assistance Application (Spanish) (PDF) Food Assistance - SNAP Appeal to the State Department of Social Services (ENG) (PDF) Appeal to the State Department of Social Services (SPA) (PDF) Application for Benefits (English) (PDF) Application for Benefits (Spanish) (PDF) Change Report (English) (PDF) Change Report (Spanish) (PDF) Elderly Simplified Application Project (ENG) (PDF) Elderly Simplified Application Project (SPA) (PDF) Renewal Application for Auxiliary Grant (AG), Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) (PDF) Renewal Application for Auxiliary Grant (AG), Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) (Spanish) (PDF) Food Assistance - The Emergency Food Assistance Program (TEFAP) Apply Online Food Assistance - Women Infants and Children (WIC) Apply Online (Web page) General Relief (GR) Appeal to the State Department of Social Services (ENG) (PDF) Appeal to the State Department of Social Services (SPA) (PDF) Application for Benefits (PDF) Benefit Programs Brochure (PDF) Notification of Change (PDF) Medicaid Application Forms by Category Children Under Age 19 Apply Online Through CommonHelp Other Ways to Apply for Medical Assistance (PDF) Parents & Caretakers of Dependent Children Apply Online Through CommonHelp Other Ways to Apply for Medical Assistance (PDF) Pregnant Women Apply Online Through CommonHelp Other Ways to Apply for Medical Assistance (PDF) Supplemental Security Income (SSI) Recipients Apply Online Through CommonHelp Other Ways to Apply for Medical Assistance (PDF) Adults Aged 65 or Older, Blind or Disabled (not receiving SSI) Apply Online Through Commonhelp ABD Medicaid Renewal (DOC) Other Ways to Apply for Medical Assistance (PDF) Children or Adults Who Need Long-term Care in a Facility/Home & Community-based Care (Waiver) Services Apply Online Through CommonHelp Other Ways to Apply for Medical Assistance (PDF) Medicare Beneficiaries Apply Online Through CommonHelp Other Ways to Apply for Medical Assistance (PDF) Plan First - Family Planning Services Apply Online Through CommonHelp Other Ways to Apply for Medical Assistance (PDF) All Other 2023 Income Limits & LTC Spousal Impoverishment Standard Changes Eff. 01-10-2023 (DOC) 2021 Income Limits & LTC Spousal Impoverishment Standard Changes Eff. 01-13-2021 (PDF) 2020 Income Limits & LTC Spousal Impoverishment Standard Changes Eff. 01-17-2020 (PDF) Affidavit of Identity for Medicaid Applicants/Recipients Residing in an Institution (PDF) Appendix D: ABD, LTC Application (PDF) (PDF) Appendix D: ABD, LTC Application (Spanish) (PDF) (PDF) Appendix E: Medically Needy Spenddown (Spanish) (PDF) Appendix E: Medically Needy Spenddown (English) (PDF) Appendix F (English) (PDF) Appendix F (Spanish) (PDF) Application for Birth Certificate (English) (PDF) Application for Birth Certificate (Spanish) (PDF) Application for Health Coverage & Help Paying Costs (English) (PDF) Application for Health Coverage & Help Paying Costs (Spanish) (PDF) Asset Transfer Undue Hardship Claim (PDF) Benefit Programs Brochure (PDF) Burial Fund Designation (PDF) Commonwealth of Virginia Voter Registration Agency Certification (PDF) Cover Virginia Additional Person Supplement (English) (PDF) Cover Virginia Additional Person Supplement (Spanish) (PDF) (PDF) Medicaid Funded Long-term Care Service Authorization (PDF) Notification of Change (PDF) Temporary Assistance for Needy Families (TANF) Appeal to State Department of Social Services (ENG) (PDF) Appeal to State Department of Social Services (SPA) (PDF) Applications for Benefits (English) (PDF) Applications for Benefits (Spanish) (PDF) Benefit Programs Brochure (PDF) Change Report (English) (PDF) Change Report (Spanish) (PDF) Direct Deposit Enrollment Authorization (PDF) Renewal Application for Auxiliary Grant (AG), Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) (PDF) Renewal Application for Auxiliary Grant (AG), Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) - Spanish (PDF) Temporary Assistance for Needy Families (TANF) Application to Add New Assistance Members (PDF) Temporary Assistance for Needy Families (TANF) Application to Add New Assistance Members (Spanish) (PDF) Child Support Child Support Administrative Appeal Request (PDF) Affidavit of Nondisclosure (PDF) Application for Child Support Services - English (PDF) Application for Child Support Services - Spanish (PDF) Change of Name Request (PDF) Debit Card Authorization (PDF) Direct Deposit Authorization (PDF) Financial Statement - English (PDF) Financial Statement - Spanish (PDF) Request for Case Closure (PDF) Request for Change of Payee Temporary (PDF) Request for Review & Adjustment (PDF) Statement of Payments - English (PDF) Statement of Payments - Spanish (PDF) Community Support Neighborhood Assistance Program (NAP)

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