This version of the form is not currently in use and is provided for reference only. Download this version of DSHS Form 09-995 for the current year.

DSHS Form 09-995 Companion Home Certification Evaluation - Washington

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What Is DSHS Form 09-995?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is the DSHS Form 09-995?
A: The DSHS Form 09-995 is the Companion Home Certification Evaluation form used in Washington State.

Q: What is a Companion Home?
A: A Companion Home is a residential setting where an individual with developmental disabilities lives with a trained caregiver.

Q: What is the purpose of the Companion Home Certification Evaluation?
A: The purpose of the evaluation is to assess the suitability of a home and caregiver for providing care to individuals with developmental disabilities.

Q: Who is responsible for completing the DSHS Form 09-995?
A: The caregiver and the individual seeking certification as a Companion Home must complete the form together.

Form Details:

Released on February 1, 2023;
The latest edition provided by the Washington State Department of Social and Health Services;
Easy to use and ready to print;
Quick to customize;
Compatible with most PDF-viewing applications;
Fill out the form in our online filing application.

Download a printable version of DSHS Form 09-995 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.