Victory Family Ministries Personal Consultation Contact Form

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General Information

First Name*

Email Address*

Last Name*

Cell Phone*

Can we text you regarding this consultation?*

Yes No

How did you hear about our ministry?*

Dependent's First Name*

Relationship to Dependent*

Dependent's Last Name*

Age of Dependent*

Are you seeking placement for your dependent at Victory?*

Yes No

If yes, describe your situation. If no, how else can we help you?*

Current Enrollment Period: '26 to '27

Next Enrollment Period: '27 to 28

When are you seeking to enroll your dependent at Victory?*

Situational Information

Rate your general home atmosphere:*

1 – Completely peaceful, calm, and supportive 2 – Mostly relaxed with occasional, normal stressors 3 – Moderately tense; stress or conflict happens regularly 4 – Highly chaotic, anxious, or unpredictable 5 – Consistently hostile, unsafe, or overwhelming

Rate your dependent's readiness and willingness to participate in our program:*

1 – fully invested and eager 2 – open but hesitant 3 – neutral or compliant 4 – reluctant or guarded 5 – actively resistant or refusing

How receptive is your dependent to counseling?*

How often does your dependent display the following attitudes/actions in your home?

Daily Stress or Tension*