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Support Groups
Finding Hope
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Resources
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Radical Life Change is Possible.
Apply HIA Online
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Birth Date
(Required)
MM slash DD slash YYYY
Sobriety Date
(Required)
MM slash DD slash YYYY
Is there an HIA Staff Member you have been working with? If so, who?
(Required)
T-Shirt Size
(Required)
Do you have a job?
(Required)
Yes
No
Is your company paying the Program Fee?
(Required)
Yes
No
If yes, please list contact name, phone number and email address to the individual to whom we should send the invoice:
Are you a parent?
(Required)
Yes
No
Have you ever been convicted of a felony or misdemeanor other than traffic offenses?
(Required)
Yes
No
Are you willing to have a criminal background check performed?
(Required)
Yes
No
Are you willing to be regularly drug tested?
(Required)
Yes
No
Are you a registered sex offender?
(Required)
Yes
No
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Why do you want to join HIA Online?
(Required)
What are three short-term goals you want to accomplish?
(Required)
What are two long-term goals you want to accomplish?
(Required)
What is one area of your life that needs improvement?
(Required)
Where, or who is your biggest trigger?
(Required)
How did you hear about Hope is Alive Ministries?
(Required)
Who are three people that are a positive influence on your life?
(Required)
What are your three best qualities?
(Required)
What is one fear or apprehension that you have when it comes to trying our online program?
(Required)
What are you most excited about in this new life of sobriety?
(Required)
We want to know more about you. Tell us your story. Briefly describe who you are, what has happened, and where you are now!
(Required)
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What We Do
HopeLine
Mentoring Homes
HIA Online
Support Groups
Finding Hope
Hope After Loss
Events
Resources
Treatment Placement
Church Partnerships
Corporate Support
School Support
University Support
Radical Magazine
Who We Are
About Us
Values
Staff
Support Us
Give
Volunteer
Contact
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