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? * 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? Is the client actively suicidal or homicidal? Does the client have a history of suicidal ideations and/or attempts? If yes, when was the last attempt? If yes, please provide details: Is the client displaying any physical signs of detoxing? Does the client require constant medical supervisions? Parent / Caregiver Information Mother's Name Mother's DOB Mother's Phone Mother's SSN# Mother's Date of Last Interaction with Client Has the mother's custodial rights been legally terminated? Father's Name Father's DOB Father's Phone Father's SSN# Father's Date of Last Interaction with Client Has the father's custodial rights been legally terminated? Conservator's / Advocate's Information Conservator's Name / Agency * Conservator's Email * 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:
Any Learning Disabilities? Health / Mental History Is the client pregnant/STD's? Does the client have health insurance? Date of last Physical Date of Last TB and Results List of known allergies or diagnoses Are immunizations current? Please upload a copy of immunization records:
Date of last dental/vision screening List of medications: Please upload any records:
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: