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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
Tulsa
Wichita
North Carolina
Greenville
Weatherford
Kansas City
Claremore
DFW
Colorado Springs
HIA Online - 90 Day Program
Which Area Are You Applying To
(Required)
OKC
Tulsa
Wichita
North Carolina
Kansas City
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
Are you a member of a federally recognized tribe? If so, which tribe?
(Required)
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?
Have you been a victim of Domestic Violence?
Do you struggle with a gambling addiction?
(Required)
Yes
No
Do you you have insurance? If so which company?
(Required)
Which Treatment Center are you coming from?
(Required)
Case Manager Name
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)
Do you have any current legal issues? (Very common)
(Required)
Have you ever been incarcerated?
(Required)
Yes
No
DOC #
Case Manager Name
Are you currently homeless?
(Required)
Yes
No
Sobriety Date (Month, Day, Year)
(Required)
Is there an HIA staff member you have been working with? If so, who?
(Required)
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 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)
(Required)
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)
What are three short-term goals you want to accomplish?
(Required)
What are two long-term goals you want to accomplish?
(Required)
What's one area of your life that needs improvement?
(Required)
Where, who, or what is your biggest trigger?
(Required)
How did you hear about Hope is Alive Ministries?
(Required)
Who are three people that are a positive influence in your life?
(Required)
What are your three best qualities?
(Required)
How long are you willing to commit the HIA Mentoring Homes and Program?
(Required)
One Year
18 Months
2 Years
What is one fear or apprehension you have when it comes to living in our homes?
(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)
What are you most excited about in this new life of sobriety?!?
(Required)
