DSHS Form 05-261 "Add, Change, or Remove Direct Service Staff for a Certified Dvit Program" - Washington

What Is DSHS Form 05-261?

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.

Form Details:

  • Released on September 1, 2018;
  • 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;

Download a printable version of DSHS Form 05-261 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download DSHS Form 05-261 "Add, Change, or Remove Direct Service Staff for a Certified Dvit Program" - Washington

659 times
Rate (4.8 / 5) 40 votes
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
DOMESTIC VIOLENCE INTERVENTION TREATMENT (DVIT) PROGRAM
Add, Change, or Remove Direct Service Staff
for a Certified DVIT Program
All forms must be signed and filled out completely. Incomplete forms will not be accepted. See Washington
Administrative Code (WAC) 110-60A for Domestic Violence Intervention Treatment (DVIT) Program standards.
There is no fee to submit this application.
Submit the completed application, and supporting documents to:
Department of Social and Health Services (DSHS)
Domestic Violence Intervention Treatment Program Certification
PO Box 45470
Olympia, WA 98504-5470
Program Information
PROGRAM NAME
TELEPHONE NUMBER (WITH AREA CODE)
PHYSICAL ADDRESS
CITY
STATE
ZIP CODE
DIRECTOR’S NAME
TELEPHONE NUMBER (WITH AREA CODE)
EMAIL ADDRESS
New or Changing Direct Treatment Staff
STAFF LEVEL REQUESTED (TRAINEE,
DSHS FORM 10-210, BACKGROUND CHECK
NAME
STAFF OR SUPERVISOR)
AND DOH CREDENTIAL ATTACHED.
Yes
Yes
Removing Direct Treatment Staff
NAME
LAST DATE OF SERVICE
Required Documentation for New or Changing Direct Treatment Staff
A statement of qualifications (DSHS form #10-210); and
A current DOH license as a licensed or registered counselor and the results of current criminal history background
checks, conducted in each state the person has lived in for the last ten years.
Attestation
I certify under penalty of perjury that the information provided in this application for certification is true and correct. I
understand that any material misrepresentation or misstatement of fact may result in sanctions, including the denial or
loss of program certification.
DIRECTOR’S SIGNATURE
DATE
PRINT DIRECTOR’S NAME
For Department of Social and Health Services Use Only
APPROVED BY:
Certified from:
to:
DSHS STAFF SIGNATURE
DATE
PRINT STAFF NAME
Page 1 of 1
APPLICATION FOR NEW PROGRAM CERTIFICATION
DSHS 05-261 (REV. 09/2018)
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
DOMESTIC VIOLENCE INTERVENTION TREATMENT (DVIT) PROGRAM
Add, Change, or Remove Direct Service Staff
for a Certified DVIT Program
All forms must be signed and filled out completely. Incomplete forms will not be accepted. See Washington
Administrative Code (WAC) 110-60A for Domestic Violence Intervention Treatment (DVIT) Program standards.
There is no fee to submit this application.
Submit the completed application, and supporting documents to:
Department of Social and Health Services (DSHS)
Domestic Violence Intervention Treatment Program Certification
PO Box 45470
Olympia, WA 98504-5470
Program Information
PROGRAM NAME
TELEPHONE NUMBER (WITH AREA CODE)
PHYSICAL ADDRESS
CITY
STATE
ZIP CODE
DIRECTOR’S NAME
TELEPHONE NUMBER (WITH AREA CODE)
EMAIL ADDRESS
New or Changing Direct Treatment Staff
STAFF LEVEL REQUESTED (TRAINEE,
DSHS FORM 10-210, BACKGROUND CHECK
NAME
STAFF OR SUPERVISOR)
AND DOH CREDENTIAL ATTACHED.
Yes
Yes
Removing Direct Treatment Staff
NAME
LAST DATE OF SERVICE
Required Documentation for New or Changing Direct Treatment Staff
A statement of qualifications (DSHS form #10-210); and
A current DOH license as a licensed or registered counselor and the results of current criminal history background
checks, conducted in each state the person has lived in for the last ten years.
Attestation
I certify under penalty of perjury that the information provided in this application for certification is true and correct. I
understand that any material misrepresentation or misstatement of fact may result in sanctions, including the denial or
loss of program certification.
DIRECTOR’S SIGNATURE
DATE
PRINT DIRECTOR’S NAME
For Department of Social and Health Services Use Only
APPROVED BY:
Certified from:
to:
DSHS STAFF SIGNATURE
DATE
PRINT STAFF NAME
Page 1 of 1
APPLICATION FOR NEW PROGRAM CERTIFICATION
DSHS 05-261 (REV. 09/2018)