Search
Home
Referrals
About Us
Reflection Story
Get Involved
Join the Team
Career Openings
Volunteer Opportunities
Events
Donate
Newsletter
Volunteer Opportunities
Resources
For Parents
Store
Contact Us
Contact Anonymously
Request A Speaker
Spotlight
Donate Today
The Village
REFLECTION HOUSE
The Cottages
Empowerment Center
Please enable JavaScript in your browser to complete this form.
Client Information
Name
*
First
Last
Last Known Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
Sexual exploitation
Forced marriage
Internet phishing
Criminal activities
Labor trafficking
Agricultural
Domestic work
Factory
Restaurant/hotel work
At risk
Other
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?
Kidnapping
Sold by family member
Sold by someone other than family
Adoption
Family visit
Friend visit
Marriage
Educational opportunity
Labor migration
Tourism
Other
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?
Abuse (physical, psychological, sexual)
Threats of harm
Giving of drugs/alcohol
False promises/deception
Denied freedom of movement
Threats of harm to others
Withholding of documents/ID/wages
Excessive working hours
Denied necessities
Threats of being handed over to police for arrest or deportation
Debt bondage
Other means of control
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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.
*
Phone
Submit