Forms

HHS forms are used every day to perform tasks such as applying for benefits, contracting to provide goods or services, reporting incidents, declaring end of life wishes, and conducting other business.

ES = Spanish version available.

Title
Form 5101, Prevention Education Attendance Roster
Form 5103, Risk and Protective Factor Screening
Form 5100, Participant Rights ES
Form 5102, Participant Information
Form 2974C, CPS Request for Risk Evaluation Based on Past Criminal History or Central Registry Findings for Foster/Adoptive Homes
Form 3600, Application for Participation in Title XIX Medicaid: ICF/IID, Nursing Facility or Rural Hospital Swingbed Program
Form 3043, MH Child and Adolescent Needs and Strengths (CANS) - Age 6-17 ES
Form 3041, MH Adult Uniform Assessment for Texas Resilience and Recovery ES
Form 4010, Informed Consent for Opiate Use Disorder Individuals Seeking Treatment – Adults ES
Form 4009, Informed Consent for Pregnant Opioid/Opiate Use Disorder Individuals Seeking Treatment
Form 2856, Child Care Licensing Homebound Fingerprint Request
Form 4008, Informed Consent for Opiate Use Disorder Individuals Seeking Treatment – Youths Ages 13 to 18
Form 0009, Notice of Intent – County Jail Reporting
Form 3040, Review Findings and Plan of Improvement
Form 0007, Notification of County Jail Confinement and Release