Demographic Information

Reason for Referral

Admissions

Parent / Caregiver Information

Conservator's / Advocate's Information

Educational History

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Health / Mental History

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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.