I ensure that all the information I am giving in this application is true. I understand that if any of the information that I have given is found false (or pertinent information omitted), it will result in loss of eligibility to the Adeara program. Please be advised Adeara is a long term recovery centre and requires a minimum commitment of 6 months to programming.
Please include other addictions not listed above
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?
Please specify your special needs
Please specify your allergies
Please specify your MEDICAL issues
Please specify your MENTAL HEALTH issues
When was your diagnosis?
Please specify your medications
Are they in your care/custody? Where are they currently living?
Does the father have any custody of children?YesNo
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?
What is your ORCA number?
What is your criminal record for?
What are the charges?
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.
What are the conditions of your parole?
When are your court dates and what are they regarding?
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
Please provide their name (first & last) and phone number so we may contact them in regard to your application.
Please specify approximately how much
Please note that BOTH the Application and Service Contract must be completed and submitted to apply to the program.