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The Village
PHASE 1
REFLECTION HOUSE
The Cottages
PHASE 2
Empowerment Center
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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
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
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
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
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
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
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:
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