Referral Form - Reflection Ministries

Client Information

Name *

First

Last

Last Known Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

SSN #

Ethnicity

Religion

Gender (male, female, or identifies as)

Primary Language

Height (inches)

Weight (pounds)

Country of Citizenship

Is the client currently in a safe place? *

Yes
No

Reason for Referral

Include background history about the client and any pertinent details:

List any outstanding warrants:

Probation Details:

Admissions

Has the client been identified or suspected as a survivor of sex trafficking?

Yes
No

What does the client hope to gain from the program?

Health / Mental Health History

Is the client displaying any physical signs of detoxing?

Yes
No

Does the client require constant medical supervision?

Yes
No

Is the client pregnant?

Yes
No

Has the client tested positive for any STD's?

Yes
No

Does the client have health insurance/Medicare/Medicaid?

Yes
No

If yes, please upload a copy of health insurance.

Click or drag a file to this area to upload.

Date of last physical exam:

Date of most recent TB test and results:

List of known allergies:

List any other medical conditions:

Are immunizations current?

Yes
No

Please upload a copy of immunization records.

Click or drag a file to this area to upload.

Date of last dental visit:

Date of last vision screening:

List of current medications:

Please upload any other medical records.

Click or drag a file to this area to upload.

Give a brief description of the mental health history of the client.

Hospitalizations, behavior history, drug/alcohol abuse history, etc.

Is the client actively suicidal or homicidal?

Yes
No

Does the client have a history of suicidal ideations and/or attempts?

Yes
No

If yes, please list dates and a brief description of each known attempt.

Trafficking/Exploitation Case Classification

Check all that apply:

If at risk or other, give details here.

Trafficking Location/Migration

Place of Origin

Destination Location

What is the main reason the client left their place of origin?

Example: ran away, recruited, relationship, kidnapped, etc.

Duration of Exploitation

How did the client enter the trafficking process?

Select all that apply.

If other, please explain here.

Date exploitation began:

Age of client at first exploitation:

Date of exit from exploitation:

Duration of exploitation:

What means were used to control the client during exploitation?

If other, give details here.

Parent / Caregiver Information

Mother's Name

Mother's Date of Birth

Mother's Address

Address Line 1

Address Line 2

City

State

Zip Code

Mother's Phone Number

Mother's SSN #

Mother's date of last interaction with client:

Have the mother's custodial rights been legally terminated?

Yes
No

Father's Name

Father's Date of Birth

Father's Address

Address Line 1

Address Line 2

City

State

Zip Code

Father's Phone Number

Father's SSN #

Father's date of last interaction with client:

Have the father's custodial rights been legally terminated?

Yes
No

Conservator's / Advocate's Information

Conservator's Name / Agency Name *

Conservator's Email Address *

Conservator's Address

Address Line 1

Address Line 2

City

State

Zip Code

Conservator's Cell Phone Number

Conservator's Office Phone Number

Conservator's Relationship to Client:

Educational History

Last School Attended

Date Last Attended

Last Grade Completed

Does the client have any learning disabilities?

Please upload any school records available.

Click or drag a file to this area to upload.

Consent for Advocacy Services

I hereby request and authorize Reflection Ministries of Texas to serve as my advocate. By signing this form, I am consenting to allow Reflection Ministries of Texas to advocate for my rights and provide guidance and resources necessary for me to make informed decisions regarding my safety and care. As my advocate, I authorize Reflection Ministries of Texas to disclose and/or receive confidential information about me, including medical and behavioral health information, academic records, and judicial records. I require Reflection Ministries of Texas to be involved in the collaborative discussions, meetings, or interventions relating to my plan of care. As a client of Reflection Ministries of Texas, I understand that my information will be protected and security-maintained adhering to HIPAA Privacy requirements and mandatory reporting laws. By signing below, I am voluntarily consenting for Reflection Ministries of Texas to serve as my advocate. Reflection Ministries of Texas will provide resources to me until I revoke my consent for their services. My signature below indicates my decision to accept advocacy services of my own free will.

Consent for Advocacy Services Digital Signature - type your full name below to sign. *