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  • HEALING TO RE-ENTRY PROGRAM APPLICATION

  • Please print. All information needs to be legible. If you need any assistance filling out this document, please contact the HTR office.

    All participants in the Healing to Re-Entry program. Must provide a copy of CDIB to apply.

  • Contact Information:

  • *N/A if doesn't apply*
  • Today's Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • DOB:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Tribal Enrollment:

  • Are you enrolled in a Federally recognized Tribe?
  • May we contact tribal enrollment to verify?

  • Application Information:

  • 1. Will you have stable housing upon your release?
  • 2. Will you have reliable transportation upon your release?
  • 3. Do you have open Indian Child Welfare/ State Child Protection / State Adult Protection cases?
  • 4. Are you a Veteran?

  • Institutional Information:

  • Check all that applies.
  • Offense(s):

  • Release Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Parole/Probation Information:

  • Parole Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Next Parole Hearing Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Sex Offense Information:

  • Date of Conviction:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Level of Offense:
  • Date Sentence Completed:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Title 1 of the Adam Walsh Act known as the Sex Offender Registration and Notification Act (SORNA):

    All sex offenders who reside, are employed, or are a student within the lands subject to tribal jurisdiction must register with the Sex Offender Registry Program. In these types of cases, sex offenders must register and keep the registration current. Additionally, all sex offender convicted by the Tribes of a covered sex offense must register. In these types of cases, sex offenders must initially register with the Tribes regardless of the sex offender's actual or intended residency. Each registered sex offender appears in person to keep registration current based on the level at which the person has been tiered. Tiering is as follows: 1) Tier 1 sex offenders appear once a year for 15 years; 2) Tier 2 sex offenders appear once every 180 days for 25 years, and 3) Tier 3 sex offenders appear once every 90 days for the life. The Tribes collaborate with US Marshalls, BIA Law Enforcement, and surrounding counties to enforce the Tribal Sex Offender Registration Act.

    Please visit the Tribes sex offender registry at https://catribes.nsopw.gov/.
    SORNA Tech Esteban Juarez can be reached @ 405-422-7456 | ejuarez@cheyenneandarapaho-nsn.gov

  • SORNA Client Registration Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • SORNA Tier:
  • Format: (000) 000-0000.

  • Substance and Mental Health Information:

  • 1. Were you under the influence of alcohol or drugs at the time of your offense?
  • 2. Are you seeking treatment or willing to seek treatment for your addiction(s)?
  • 3. Have you been in a sober-living or interested in sober living opportunities?
  • 4. Are you experiencing suicidal/homicidal thoughts?
  • 5. Are you under the influence of substances at the time of this application?

  • Disclaimers:

    1. At the application intake assessment appointment, please provide a detailed substance abuse history when asked by staff.
    2. At the application intake assessment appointment, program staff will drug test you.
    3. If accepted into the program, you will be expected to follow and complete an Individualized Care Plan.
    4. If accepted into the program, you will be expected to follow and agree to program agreements.
    5. The Healing to Re-Entry Program is federally funded and requires the program to meet and/or follow certain criteria/policies.

  • Program Client Rights:

    1. The client has the right to request a program director at any time.
    2. The client has the right to confidentiality.
    3. The client has the right to refuse or question referrals.
    4. The client has the right to advocacy.
    5. The client has the right to question application acceptance or denial.
    6. The client has the right to ask for copies of ICP or other program documents.
    7. The client has the right to be respected and treated fairly.
    8. The client has the right to request program involvement in legal matters.
  • I hereby make an application for reintegration services to the Cheyenne and Arapaho Re-entry program. I acknowledge that as an applicant for admission to the Healing to Re-Entry Program I have an affirmative duty to complete the application by responding to the questions herein truthfully, fully, and completely. I also acknowledge that my failure to complete the application by responding to the questions herein truthfully, fully and completely, will result in denial of the application for admission. Also any and all supporting documentation must accompany the application in order for it to be acknowledged as complete. No applications will be processed unless any and all available documentation is submitted.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Healing to Re-Entry
    100 W. Black Kettle Boulevard
    P.O. Box 102
    Concho, OK 73022
    Office Phone: 405-422-7423
    Fax: 405-422-8216
    Email: healingtoreentry@cheyenneandarapaho-nsn.gov

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