Referral Form - Reflection Ministries

Demographic Information

Client's Name

Last Known Address

Date of Birth

SSN#

Ethnicity

Religion

Gender (Male, Female, or Identifies as:)

Primary Language

Height (inches)

Weight (pounds)

Country of Citizenship

Is client currently in a safe place? *

Yes
No

Reason for Referral

Include background history about the client and any pertinent details:

Outstanding Warrants:

Probation Details:

Admissions

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

Yes
No

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, when was the last attempt?

If yes, please provide details:

Is the client displaying any physical signs of detoxing?

Yes
No

Does the client require constant medical supervisions?

Yes
No

Parent / Caregiver Information

Mother's Name

Mother's DOB

Mother's Address

Address Line 1

Address Line 2

City

State

Zip Code

Mother's Phone

Mother's SSN#

Mother's Date of Last Interaction with Client

Has the mother's custodial rights been legally terminated?

Yes
No

Father's Name

Father's DOB

Father's Address

Address Line 1

Address Line 2

City

State

Zip Code

Father's Phone

Father's SSN#

Father's Date of Last Interaction with Client

Has the father's custodial rights been legally terminated?

Yes
No

Conservator's / Advocate's Information

Conservator's Name / Agency *

Conservator's Email *

Conservator's Address

Address Line 1

Address Line 2

City

State

Zip Code

Conservator's Cell Phone

Conservator's Office Phone

Conservator's Relationship to the Client

Educational History

Last School Attended

Date Last Attended

Last Grade Completed

Please upload any school records available:

Click or drag a file to this area to upload.

Any Learning Disabilities?

Health / Mental History

Is the client pregnant/STD's?

Does the client have health insurance?

Yes
No

Please upload a copy of health insurance:

Click or drag a file to this area to upload.

Date of last Physical

Date of Last TB and Results

List of known allergies or diagnoses

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/vision screening

List of medications:

Please upload any records:

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 Advocay Services Digital Signature - Type Your Full Name Below to Sign: