MODIFY Intake Form

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Required format:

hbn2AE9q7zvBx4qWAJmatqAni3QDXLMgLE5hBhx98YtRTNWTY9cJkXBqrjtkBSd4jHvdRchGMppfLaMhVhtC

Please complete the intake form below for the MODIFY Program.

If you have trouble accessing this form, please contact Michelle Fleece, MODIFY Program Manager, at mroyer@hsc.wvu.edu or 304-288-4350.

If you do not hear from a MODIFY specialist regarding your referral within one week, please contact Michelle Fleece, MODIFY Program Manager, at mroyer@hsc.wvu.edu or 304-288-4350.

Fall Semester Enrollment

Referral Deadline: June 1
All paperwork in: July 1

Spring Semester Enrollment

Referral Deadline: Oct. 1
All paperwork in: Nov. 1

Summer Session Enrollment

Referral Deadline: Mar. 1
All paperwork in: Apr. 1

Required Documentation:

Copy of acceptance letter to a WV college/university/Pell-approved certificate program
Copy of FAFSA verification
Copy of high school diploma/equivalent
Student ID number

WVUMedicine Notice of Privacy Practices

Type of Referral:

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Information Referral: Doesn't have the required documentation to open services

Services Referral: Has required documentation to open services.

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Referring Source Name

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Organization

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Referral Date

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D-M-Y

Referring Source Phone

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Referring Source Email

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Name of Youth

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DHHR Case Number

DHHR Client ID Number

Current Address

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City

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State

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Zip

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Telephone Number

Email Address

Birth Date

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M-D-Y

Gender

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What are your pronouns?

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She/her

He/him

They/Them

Not listed above

Prefer not to say

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Please list your pronouns.

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Race

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Ethnicity

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Was this youth adopted or placed in legal guardianship after the age of 16?

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Yes

Unknown

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Did this youth turn 18 years of age while in foster care?

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Yes

Unknown

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If under 18 years of age, will this youth move into post-secondary education or employment while still in foster care?

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Yes

Unknown

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Does this youth plan to attend school or begin work?

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Technical/Trade School

2 Year Community College

4 Year College/University

Work

Undecided

Unknown

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Describe any specific or additional plans this young person has for their future (e.g., specific schools, Degree programs, jobs, housing, etc.)

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Highest grade completed:

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GED

High School Diploma

Working on GED or Diploma

Some Higher Education

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If this youth has not completed the GED or their high school diploma, is he/she within six months of graduation or completion?

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Yes

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Please describe any disabilities or learning disabilities of this youth, to include their involvement in special education in their K-12 schooling.

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What steps have been taken towards post-secondary education or employment?

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Services Requested

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Educational Services

Other

List One Name of Adult Connection this Young Person Maintains:

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Connection Street Address

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Connection City

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Connection State

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Connection Zip

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Connection Telephone Number

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Connection Email Address

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What other information is important for the transition of this youth to adulthood?

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Please provide a current high school transcript and IEP information if available.

Upload file

Please upload High School Diploma/Equivalent or transcript if available.

Upload file

Please upload the Acceptance Letter if available.

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Please upload the FAFSA Verification if available.

Upload file

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