Hope Center Application                                                                                                                                                                                                                     

Download the application here: Hope Center Application

or fill out out online. 

Please fill out the application completely. Incomplete applications will not be accepted. You may or may not be contacted again if your application is incomplete. Be sure to answer every question. If you are accepted into the program and it is later discovered that you have provided false information on your application, disciplinary action will result up to and including termination from the program.

Once  your application is reviewed in a timely manner, you will receive a phone call setting up a time for a phone or personal interview with the program manager.

SPECIAL NOTE: Your application is confidential. It will be reviewed by authorized personnel only and secured properly. No one answer on this application will necessarily disqualify an individual from being accepted. The Hope Center is an equal opportunity institution and opposes discrimination in any form.

Before you complete this application, please note that the Hope Center is a faith-based drug rehab/Christian discipleship program and may not be for everyone.

 

GENERAL INFORMATION

Date

Name

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Date of Birth

Age:

Social Security Number:

Gender:
 Male

Race/Ethnicity:
 White American African American Native American Hispanic and Latino American Other

Marital Status:
 Single Married Divorced

Do you have children:
 Yes No

If yes, please list the name and ages of your children:

Do you have a high school diploma or G.E.D.?
 Yes No

Who referred you to this program?

What is your relationship to your referral?

Referrals Phone Number:

Referrals Email Address:

FINANCIAL INFORMATION
Child Support per Month: $
Probation Fee: $
Student Loan: $
Alimony(per month): $
Court Cost: $
Law Suit Amounts: $
Other Expense: $

Driver license number:

State drivers license issued in:

Drivers license status:  Valid Revoked

SUBSTANCE ABUSE INFORMATION
Years I have battled substance abuse:

Specific drug(s) of choice:

List all illegal drug(s) you have used in the past:

List all alcoholic beverages you have abused in the past:

Number of DUI's on your police record:

Do you currently smoke tobacco?  Yes No

Do you currently use smokeless tobacco?  Yes No

Have you abused prescription medication?  Yes No
If yes, please list all:

Are you currently detoxed?  Yes No

Have you ever been arrested?  Yes No

Please give details of your arrest(s):

Have you ever been convicted of a felony or plead no contest to a felony?
 Yes No

Please give details of your felony conviction?

List any felony charges:

Have you spent time in jail?  Yes No

If yes, how long were you incarcerated at each occurrence?

Do you currently have any outstanding warrants for your arrest?  Yes No

Are you on probation?  Yes No

If yes, where?

Who is your probation officer?

Please give your probation officers phone number:

Are you a registered sex offender?  Yes No

Do you have health insurance?  Yes No

You will be required to take a physical exam, do you have a problem with that?  Yes No

Are you willing to release the results of the physical to the Hope Center administrators?  Yes No

IMPORTANT: The Hope Center is not responsible for any healthcare bills. That is solely your responsibility to arrange a verifiable contact person(spouse, parent, etc.) and address for healthcare professionals to send any medical bills you might incur during your residency at the Hope Center. Your designated person will be contacted to verify that they will be responsible for any of your medical bills.
Have you read and do you understand the above statement?  Yes No

Name and phone number of person responsible for your healthcare bills:

Address of person responsible for your healthcare bills:
Street address:
City:
State:
ZIP:

Do you currently draw Social Security/Disability?
 Yes No
If yes, please list how much per month and when?

Do you wear glasses or contacts?  Yes No

Do you feel like you need to see an eye doctor? Yes No
If yes, please give a reason:

Do you feel like you need to see a dentist? Yes No
If yes, please give a reason:

Do you currently have any of the following health issues?
I have tested positive for HIV/AIDS?  Yes No
Communicable disease?  Yes No
If yes, please list:

Hepatitis?  Yes No
If Yes, what type of hepatitus?
Sexually Transmitted Disease? Yes No
If yes, please list:

Undergoing or completed treatment for STD?  Yes No
If yes, please explain:

List any other current diseases not listed above:

Do you have any current injuries?  Yes No
If yes, please list:

Do you have any current allergies?  Yes No
If yes, please list?

Do you have any current disabilities?  Yes No
If yes, please list:

Are you currently taking medication prescribed by a doctor?  Yes No
If yes, please list each medication, dosage, and frequency you take the medication:

List each physician's name who prescribed you this medication(s):

Do you have any special dietary needs?  Yes No
If yes, please list:

IMPORTANT! Unless a physician instructs otherwise, you will be required to exercise your body 5 days/week at 6:00am each weekday morning. Like boot camp is to the Army, physical training is also important to the Hope Center and is mandatory part of our program.

Are you willing to submit to the physical training part of our program?  Yes No
If no, explain:

Have you been diagnosed with any of the following mental health issues?
Bi-polar:  Yes No
If yes, please explain:

Paranoid:  Yes No
If yes, please explain:

Schizophrenic:  Yes No
If yes, please explain:

Depression:  Yes No
If yea, please explain:

BEHAVIOR INFORMATION:
IMPORTANT! Submission to authority doesn't even occur until you first disagree with an authority figure but agree to what he/she asks despite your disagreement.

How will you cope with the many layers of authority over you giving you daily instruction?

IMPORTANT!
We have found that people battling life controlling issues only change when one of two things happen: (1)they are hurting bad enough that they have to or (2)they are hungry enough that they want to change. In which condition are you?
 Hungry for change Hurting bad enough for change

List any previous drug rehabilitation programs that you have been involved with:

Why do you want to enroll in the Hope Center?

The Hope Center is a Christ-centered, faith-based program. Why would you want to attend a Christian discipleship program?

Do you want to be free from addictive behaviors?
 Yes No
If yes, explain:

Our program is very strict with stringent rules, regulations, and restrictions. How would you deal with such a structured environment?

In addition to classroom instruction, our men perform physical labor every weekend and virtually every Saturday. How will you cope with such a physically demanding environment?

Are you aware that the Hope Center is a minimum 12-month program?
 Yes No

What makes you think you can complete a one year program?

How can we be sure that you will, if accepted, fully commit to complete the 12-month program and won't waste our time and yours?

This is your one chance to say anything you would like to us:

The Hope Center is a tobacco-free environment. You will be required to stop smoking, dipping, chewing when you enter the Hope Center. By accepting the terms below, you are certifying that all the information provided is true, and you understand that if later we discover that you have falsified any information in this application, you can be terminated from the program.
FINANCIAL AGREEMENT AND RESPONSIBILITY ACKNOWLEDGEMENT STATEMENT
Non-refundable Registration Fee: $500.00
Although we do not charge for the program, there is a $500.00 non-refundable registration/administration fee. This fee in no way covers the cost that this ministry incurs to house, feed, transport and do the day-to-day operations that must be done for the program to be successful. If you are accepted into the program and it is later discovered that you have provided false information on your application, disciplinary action will result up to and including termination from the program.
ACKNOWLEDGEMENT:
I have read the above financial agreement and Responsibility Acknowledgement Statements and understand them. Also, I understand that all fees are due the first day you are officially enrolled.

Name:

Date: