Breakthrough Re-engagement Request Form

We're so glad to have reconnected with you and would like to understand the best way to support you in your next steps! Please complete this short form. This will also help us know your plans and keep you connected with the BT community. After you submit this form, someone from the college team will follow up within the next month.

General Information

Name

Email LScommittee@breakthroughctx.org if you cant find your name

Preferred Name

Pronouns

Mobile #

Best way to contact you

Best time of day to contact you?

Date of Birth

EXACT FORMAT: yyyy-mm-dd

It looks like the Date of Birth you inputted does NOT match our records. Please make sure you are following the correct format of YYYY-MM-DD . If you are still having issues please reach out to a BT staff or LScommittee@breakthroughctx.org to see what information we have in our records before proceeding.

Enrollment Information

Let us know your enrollment status

Have you obtained a HS diploma or GED?

Are you planning to enroll in school or a trade program?

What pathway are you trying to pursue?

What school or program are you enrolled in?

What goals or next steps are you wanting support from Breakthrough with?

College Team Re-Engagement Policy

IMPORTANT: Please carefully review before continuing

Breakthrough is here to support you as you navigate college and career goals. We commit to supporting you for up to 6 years after you graduate from high school (or complete a Bachelors degree). Your advisor will:

- Show up prepared for meetings

- Help you make a plan tailored to your goals

- Provide resources and encouragement

Your commitment to us

Please read each of the statements below and check the box showing you agree:

A Breakthrough College Team staff member will review this form after you submit and attempt to reach and communicate next steps. If we do not hear from you within 2 weeks of our outreach attempt, you will be transitioned back to a Limited Service status and invited to reach back out whenever you are ready! At that time, you will complete this form once again.

Students re-engaging with Breakthrough after being on Limited Service and requesting a BT advisor are expected to communicate with their advisor within 30 days of being assigned to the advisor. After 30 days, students will be transitioned back to a Limited Service status.

Students requesting to be reconnected with a Breakthrough advisor will be expected to attend a Re-engagement Meeting with a College Team Staff member within two weeks before being officially assigned an advisor.

Please confirm you have read everything above and understand this policy by checking the box below

I understand and agree to the Breakthrough College Team Re-engagement Policy

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Expected DOB

Today's Date

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Contact Information