Forms & Applications

This section contains forms for both the adult foster care licensing / relicensing process and forms pertaining to adults currently in care. For further information or assistance, please call 651-213-5200.

Available Forms

• Background Study Release of Information (PDF): This is 1 part of the NET study process. It is used to obtain a background check on provider, any other person living in the household who is age 13 or older, and alternative care providers / employees.
• Caregiving for Adults - Social History: These forms are for home study as part of the initial licensing.
  Part 1 (PDF) | Part 2 (PDF)
• Chemical Usage Policy (PDF): This policy should be completed and signed by the license holder, with a copy of the original sent to the licensor, and signed copies by all employees and residents kept in the provider's file.
• Highlight Sheet (PDF): A quick review of qualifications and regulations.
• Home Safety Checklist (PDF): Completed by licensor at initial licensing and relicensing thereafter.
• Medical Equipment Training Form (PDF): To be used for each caregiver for each resident.
• Medication Record (PDF)
• Program Abuse Prevention Plan (PDF)
• Program Plan (PDF)
• Rule 203 (PDF): The Adult Foster Care Rule
• Minnesota State Statute (MSS) 2013 - Chapter 245D (PDF): Home and Community-Based Services Standards (Effective January 1, 2014)
• Mandated Reporting Guide