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 5110, Youth Prevention Universal Program Participation Letter ES
Form 5108, Youth Prevention Universal Family Focused Participation Letter ES
Form 5109, Youth Prevention Universal Parent/Guardian Opt-Out Signature
Form 5107, Parent/Guardian Consent Signature
Form 5106, Youth Prevention Indicated and Youth Prevention Selective Verbal Consent ES
Form 5105, Youth Prevention Indicated Program Participation Letter
Form 5104, Youth Prevention Indicated Family Focused Program Participation Letter ES
Form 5101, Prevention Education Attendance Roster
Form 5103, Risk and Protective Factor Screening
Form 5100, Participant Rights ES
Form 5102, Participant Information
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