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VICTORY HOUSE STUDENT APPLICATION
When you are ready to reserve a place there
is a non refundable $200.00 induction fee.
Call to check if we are accepting applications
COVID-19 UPDATE- WE ARE ACCEPTING APPLICATIONS WITH A DOCTORS APPROVAL OF HEALTH
Name
Prefix
First
Last
Suffix
MI
Middle
Your Name(s)
*
Your Email Address
*
Secondary Email
Your Daughter's Name
*
Your Daughter Age
Your Daughter's
Birthdate
MM
/
DD
/
YYYY
Your Address
*
Street Address
*
Address Line 2
City
*
State / Province / Region
*
Postal / Zip Code
*
Country
*
Your Primary
Phone
*
###
-
###
-
####
Your secondary
Phone
###
-
###
-
####
Family History
Joint custodian's
Name
If applicable
Your joint custodians
spouses Address
If applicable
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Joint custodian's
Phone
If applicable
###
-
###
-
####
What is your current
Home situation
Please select
Both Parent home
Single parent home
Mother & Step Father
Father & Step Mother
Legal Gaurdian
Has there been a significant
loss or change in the family
recently?
Yes
No
What is the
Family stress-er?
Are both Parents
in agreement to
consider placement
of your daughter?
Yes
No
Not Sure
How many siblings
are in the home
while your daughter
is in the home.
Only Child
1-2
3-4
4 or more
What is your
daughter's birth order
(in relationship to her
other siblings)
Please select
first born
second child
Third Child
Other
Baby of the family
Problematic History
At what age did
your daughter's
problems begin
presenting themselves?
Is your daughter
under court supervision?
Yes
No
Is your Daughter
Depressed?
Yes
No
Please rate her
depression.
Please select
Severe
Medium
Mild
Is your Daughter
suicidal?
Yes
No
Has she attempted
suicide?
Yes
No
How many times?
1-2
3-4
5 or more
Has your daughter
been the victim of
abuse?
Yes Sexual
Yes Physical
Yes Emotional
No
Not Sure
Is your daughter
violent towards her
peers?
Yes
No
Is your daughter
sexually active?
Yes
No
Not Sure
Has Your daughter
displayed lesbian
tendencies?
Yes
No
Not Sure
Will your daughter be
a runaway risk while
she is at Victory House?
Yes she May be
No, I don't think so
Has your daughter
been involved with
occultist activities?
Yes
No
Not Sure
Tell us about your
daughter's behavior and
Treatment history. Please
be frank and tell us what
you feel we need to know.
*
School History
School's Name
School's Address
What is the last grade
your daughter completed.
Does your daughter have
a Learning disability?
Yes
No
Not Sure
Medical History
Is your daughter
currently under a
physician's care?
Yes
no
Please list any
medications your
daughter is currently
taking
Does your daughter have
any dietary restrictions?
Yes
no
What are they.
Does your daughter
have any physical
limitations
Yes
No
What are they
Does your daughter
have any allergies
Yes
No
What are they
What do you wish
to accomplish by sending
Your Daughter to
Victory House?
What is your Daughters
Presenting Problems?
(for instance lying-
stealing-promiscuous,
temper, sneaking out ect.)
What drugs has your daughter
been using?
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