Hijrah House Application Intake Form
Established in 2025, Hijrah House (pronounced HIDJ-rah) is a Muslim faith-centered and recovery-focused transitional home for men in Central Indiana. As a nonprofit subsidiary of Mumineen Community Development Corporation, Hijrah House provides a safe and supportive environment for men facing housing instability, justice involvement, career setbacks, trauma, and other life challenges. Our programs are designed to uplift and guide residents toward renewed stability, self-sufficiency, and restored dignity—helping them transition into healthier, more purposeful lives.
APPLICANT INSTRUCTIONS:
Complete each section of the form. After completion, please email rpowell@mumineencdc.org or jmansa@mumineencdc.org or call (317) 296-5020, and select option #2.
SECTION 1: BASIC INFORMATION
APPLICANT FULL LEGAL NAME
First Name
Last Name
APPLICANT GENDER
MALE
FEMALE
APPLICANT DATE OF BIRTH
-
Month
-
Day
Year
Date
APPLICANT PHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
APPLICANT CURRENT AGE
APPLICANT SOCIAL SECURITY NUMBER (SSN)
APPLICANT IDENTIFICATION CARD NUMBER
Passport, State ID Number, Drivers License Number, etc.
APPLICANT IDENTIFICATION CARD TYPE
STATE ID CARD
DRIVERS LICENSE
PASSPORT
MILITARY ID
SCHOOL ID CARD
Other
UPLOAD A COPY OF YOUR ID
APPLICANT CURRENT ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
APPLICANT EMAIL ADDRESS
example@example.com
APPLICANT MARITAL STATUS
Please Select
MARRIED
SINGLE
DIVORCED
WIDOWED
SEPARATED
WHAT IS YOUR HIGHEST LEVEL OF EDUCATION?
Please Select
GED/HSE
HIGH SCHOOL DIPLOMA
SOME COLLEGE
TRADE OR TECHNICAL SCHOOL
ASSOCIATES DEGREE
BACHELOR DEGREE
MASTER DEGREE
GRADUATE DEGREE
WHAT IS YOUR RACE OR ETHINICITY?
AFRCIAN AMERICAN OR BLACK
WHITE
LATINO OR HISPANIC
ASIAN
ARAB
AFRICAN
EUROPEAN
BI-RACIAL
MULTI-RACIAL
Other
MIITARY SERVICE BRANCH
ARMY
NAVY
MARINES
AIR FORCE
SPACE FORCE
NATIONAL GUARD
SECTION 2: EMERGENCY CONTACT INFORMATION
EMERGENCY CONTACT NAME
First Name
Last Name
EMERGENCY CONTACT PHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
EMERGENCY CONTACT ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMERGENCY CONTACT RELATIONSHIP
SPOUSE
PARENT
GUARDIAN
FRIEND
CO-WORKER
SPONSOR
PEER RECOVERY COACH
CASEWORKER
CHILD
OTHER
SECTION 3: PERSONAL CHALLENGES INFORMATION
1) Do you identify as a person in recovery from Substance Abuse, Post Traumatic Stress Disorder, Post Incarceration Syndrome, Homelessness, or other types of challenges?
YES
NO
2) Do you have any known mental health challenges or conditions?
YES
NO
3) If yes to question 2, please indicate challenge or condition
4) Have you ever received substance abuse counseling?
YES
NO
5) What is your longest period of sobriety?
1-3 months
3-6 months
6-12 months
1 - 3 years
3+ years
6) Do you have a sponsor or Peer Recovery Coach? If yes, please provide the name and contact information.
7) Have you ever participated in a community program? If so, please indicate the name (examples: 12 Step, Alcoholics Anonymous, etc.)
SECTION 4: MEDICAL INFORMATION
1) Are you currently under medical supervision?
YES
NO
2) If yes, who is your supervising person? (Name and phone number)
3) Do you require a wheel chair or ramp?
YES
NO
4) Do you have any disabilities that we need to know about?
5) Do you have problems with climbing stairs
YES
NO
SECTION 5: EMPLOYMENT INFORMATION
1) Are you currently employed?
YES
NO
2) If yes, where?
3) Work schedule (Days and Hours)
4) Position held
5) What is your pay rate?
6) How often are you paid?
WEEKLY
BI-WEEKLY
MONTHLY
OTHER
7) How long have you been employed at this job?
SECTION 6: LEGAL INFORMATION
1) Do you have any felony convictions or pending charges?
YES
NO
2) If Yes, what state?
3) Do you have any misdemeanor convictions or pending charges?
YES
NO
4) If Yes, what state?
5) Are you currently under supervision? (Probation, Parole, GPS monitoring, etc)
YES
NO
6) If Yes, what office and county?
7) If you are under supervision, what is your supervisor, probation, or parole officer name and contact information?
8) Do you have a history of incarceration? If yes, please provide DOC#
SECTION 8: ACKNOWLEDGEMENT
I (Applicant) acknowledges that the information given in this application is correct to the best of my knowledge, if there is any deception my participation in the Hijrah House program and residential license will be immediately terminated. If I am accepted into, I will abide by the Hijrah House rules, regulations, and code of conduct.
YES
NO
APPLICANNT SIGNATURE
WHO COMPLETED THIS FORM?
Please Select
APPLICANT
CASE WORKER
GUARDIAN
PAROLE OR PROBATION OFFICER
PEER RECOVERY COACH
OTHER
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