Close
Skip to content
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
Blog
Who We Are
About Us
Values
Staff
Support Us
Give
Volunteer
Contact
Menu
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
Blog
Who We Are
About Us
Values
Staff
Support Us
Give
Volunteer
Contact
Apply Now
Radical Life Change is Possible.
Apply HIA Online
Step
1
of
2
50%
Please Indicate Your Gender
(Required)
Male
Female
Which Area Are You Applying To
(Required)
OKC, OK
Tulsa, OK
Wichita, KS
Beaufort, NC
Greenville, NC
Weatherford, OK
Kansas City, KS
Claremore, OK
Arlington, TX
Colorado Springs, CO
HIA Online - 90 Day Program
Which Area Are You Applying To
(Required)
OKC, OK
Tulsa, OK
Wichita, KS
Hubert, NC
Kansas City, MO
HIA Online - 90 Day Program
Applicant Information
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Birth Date
(Required)
MM slash DD slash YYYY
T-Shirt Size
(Required)
Race: How would you describe yourself?
(Required)
American Indian or Alaska Native
White, Caucasian
Asian
Black or African American
Native Hawaiian or Pacific Islander
Latino, Hispanic or of Spanish origin
Other
Are you a member of a federally recognized tribe? If so, which tribe?
(Required)
Is there an HIA staff member you have been working with? If so, who?
(Required)
How did you hear about Hope is Alive Ministries?
(Required)
How long are you willing to commit the HIA Mentoring Homes and Program?
(Required)
One Year
18 Months
2 Years
Are you a Veteran?
(Required)
Yes
No
Are you a registered sex offender?
(Required)
Yes
No
Do you Struggle with Mental Health?
(Required)
Yes
No
Have you been a victim of Human trafficking?
Yes
No
Have you been a victim of Domestic Violence?
Yes
No
Do you struggle with a gambling addiction?
(Required)
Yes
No
Do you have health insurance? If so which company?
(Required)
Have you recently been to detox or an inpatient facility? If so, what facility?
(Required)
Which Treatment Center are you coming from?
(Required)
Case Manager Name
Are you currently or have you ever been on medication-assisted treatment (MAT)? (example: methadone, suboxone, Sublicade, etc.)
(Required)
Yes, I currently am
Yes, but not currently
No, I never have
Thank you for your interest in the program. At this time we are not able to accept any registered sex offenders. If you have any questions, please reach out to our office at (844) 346-7366
Drug of Choice?
(Required)
Are you currently on any medications? If so, please list them.
(Required)
Do you have any current or past legal issues? If so, describe them.
(Required)
Do you have any active warrants?
(Required)
Yes
No
Do you have a valid form of ID?
(Required)
Yes
No
Have you ever been incarcerated?
(Required)
Yes
No
DOC #
Case Manager Name
Are you currently experiencing homelessness?
(Required)
Yes
No
Are you currently in a safe environment?
(Required)
Yes
No
Sobriety Date (Month, Day, Year)
(Required)
MM slash DD slash YYYY
Do you have the ability to pay the first months rent ($750) the day you check in?
(Required)
Yes
No
Do you have a job?
(Required)
Yes
No
Are you a parent?
(Required)
Yes
No
Do you have transportation?
(Required)
Yes
No
Have you ever been convicted of a felony or misdemeanor other than minor traffic offenses?
(Required)
Yes
No
Are you willing to have a criminal background check preformed?
(Required)
Yes
No
Are you willing to be regularly drug tested?
(Required)
Yes
No
When do you expect to be ready to move in? (Month/Day/Year)
(Required)
MM slash DD slash YYYY
Emergency Contact Name
(Required)
Emergency Contact Phone
(Required)
Spouse Name
(Required)
Spouse Phone
(Required)
Parents Names
(Required)
Parents Phone
(Required)
Why do you want to move into the HIA program?
(Required)
Who are three people that are a positive influence in your life?
(Required)
What is one fear or apprehension you have when it comes to living in our homes?
(Required)
