Resident Admission Application

Yes

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.

Personal Information
Substance Use
NoneGamblingSex addictionPornInternetEating disordersFood addictionShoppingRelationshipsOther

Treatment History
YesNo

Health
YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

Family
YesNo

YesNo

YesNo

YesNo

Legal
YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo
Yes, I give my consentNo, I do not give my consent

Miscellaneous
YesNo

YesNo

YesNo

YesNo


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

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