Referral for Victory High School
Thank you for your interest in Victory High School, the first Recovery High School in Tampa Bay!
Victory High School is a life-changing option for students and families. We are a non-profit, private high school in Pasco County, Florida for teens in recovery from substance-use disorders or co-occurring disorders. Here, students can earn their diploma away from the pressures and temptations of traditional high school.
By completing this form, it does not guarantee enrollment. A staff member will contact you as soon as this is submitted to ask further questions and conduct an in-person interview with the student and parent/guardian before admission.
* Required
Email address
*
Your email
Parent/Guardian Name(s)
*
Your answer
Student Name
Your answer
Email
*
Your answer
Does student have 1 day substance free?
*
Not Sure
No
Yes
Has the student recently completed drug treatment?
*
Yes
No
Not Sure
Required
3.) Is student involved in or expected to be involved in after-care treatment?
Yes
No
Not Sure
Clear selection
Does the student display a sincere desire to stay sober and work a program of recovery?
*
Yes
No
Maybe
Is there any court involvement with this student?
*
Yes
No
Not Sure
Has this student been charged with any crimes? If yes, please list below.
*
Your answer
Are there other wrap around services provided to the student such as a social worker or therapist?
*
Yes
No
Not Sure
Is the student currently receiving any special education services?
*
Yes
No
Not Sure
9.) Does the student express a desire to be a part of Victory High School?
*
Yes
No
Maybe
Please check all those that apply to students needs.
*
Education
Credit Recovery
Recovery Support
Mental Health Services
Financial Assistance
Food
Shelter
Clothing
Medical Services
Required
Our Promise to You
We believe that Recovery is process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential. While sobriety and being substance free is a physical state of being, Recovery is a way of life. Our goal is to guide all students through the process of early Recovery and provide their family with resources to live productive successful lives.
Please print your name if you agree with the statement above. A staff member will be in contact soon to review your submission and schedule an in-person interview with your student and parent/guardian.
*
Your answer
Send me a copy of my responses.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
