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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
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
*

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Your secondary
Phone

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-
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####

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

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####
What is your current
Home situation
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)

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.
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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