Personal Information Legal Name Preferred Name Date of Birth Marital Status SingleIn relationshipMarriedDivorcedCommon-law Email Phone Who does this number belong to? Current living situation What culture do you identify with? (e.g. Caucasian, Asian, Indigenous, etc) How did you hear about Adeara? Substance Use 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 check off all other addictions that apply to youNoneGamblingSex addictionPornInternetEating disordersFood addictionShoppingRelationshipsOther Please include other addictions not listed above Treatment History 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? Health 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 Do you have any dietary restrictions? (doctors note required) YesNo Please specify your dietary restrictions 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 Family 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 date of birth / gender / first and last name? Any other pertinent information about your children? Legal 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 Miscellaneous Do you have a Support/Social Worker? YesNo 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. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.