Resident Admission Application - Adeara Recovery Centre

First and Last Name

Preferred Name

Date of Birth

Marital Status

Phone

Who does this number belong to?

Alternative Phone

Who does this alternative number belong to?

Current living situation

What culture do you identify with? (e.g. Caucasian, Asian, Indigenous, etc)

How did you hear about Adeara?

What is your drug of choice?

How long have you been using?

Please describe your pattern of use (how often, how much, etc...)

Date of last use

Do you use any other drugs? (If yes, specify)

Please include other addictions not listed above

Have you been to treatment before? YesNo

Where?

Approximate date(s) of each treatment centre

Did you complete their program (if more than one, specify which treatment program)?

How long did you remain in recovery after attending this treatment program (if more than one, specify which treatment program)?

Why do you want to attend residential treatment at Adeara?

Do you have any special needs we need to be aware of? (mobility access, vision or hearing impairments, etc...) YesNo

Please specify your special needs

Do you have any allergies? (foods, medication, environmental) YesNo

Please specify your allergies

List all medications that you are taking (including all over-the-counter drugs – vitamins, herbal medicines, Tylenol, etc).
Note: Adeara does not allow Methadone or Suboxone. All clients must be off these medications for minimum 60 days (proof required)

Do you have any MEDICAL issues? (communicable diseases, etc...) YesNo

Please specify your MEDICAL issues

Do you have any MENTAL HEALTH issues? YesNo

Please specify your MENTAL HEALTH issues

Have you ever been professionally diagnosed (by a medical professional)? YesNo

When was your diagnosis?

Are there any medications that you are currently taking for your mental health issue? YesNo

Please specify your medications

Are you pregnant? YesNo

Please include due date (if known)

Do you have any children? YesNo

Are they in your care/custody? Where are they currently living?

Does the father have any custody of children?YesNo

Please elaborate

Children age 10 or younger may be eligible to live at Adeara once the mother is stabilized. Are you interested in having your children at Adeara? YesNo

What is your children’s age (and birthdate), gender, and first and last name?

Any other pertinent information about your children?

Please be advised that Adeara may request supporting documents for all legal information listed below. As previously mentioned, if any of the information given is found false or pertinent information omitted, it will result in loss of eligibility to or dismissal from the Adeara program.

Are you currently incarcerated? YesNo

Be advised: Adeara houses women and children. The severity of your charge(s) will determine your acceptance to the program.

What is your ORCA number?

Do you have a criminal record? YesNo

What is your criminal record for?

Are you currently facing any charges?YesNo

What are the charges?

Are you currently on probation?YesNo

What are the conditions of your probation?

Clients with probation or parole orders please be advised: Adeara will require a copy of your conditions prior to acceptance and/or entering the Adeara program.

Are you currently on parole?YesNo

What are the conditions of your parole?

Do you have upcoming court dates?YesNo

When are your court dates and what are they regarding?

Do you have a lawyer?YesNo

Please include their first and last name and phone number

Please click “yes” to give consent to an Adeara Staff to contact your lawyer and discuss intake details (if necessary)Yes, I give my consentNo, I do not give my consent

Additional Notes / Information

Do you have a Support/Social Worker?

Please provide their name (first & last) and phone number so we may contact them in regard to your application.

Do you currently owe any debts? YesNo

Please specify approximately how much

Do you have any gang affiliation? YesNo

Please elaborate.

Do you have any family or friends with gang affiliation? YesNo

Please elaborate.

Is there any other information you believe is important for Adeara to know?

Please note that BOTH the Application and Service Contract must be completed and submitted to apply to the program.

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