NM Wellness Application

Referral Information
Are You Being Referred By An Agency? (CYFD, Court Compliance, Hospital, Detox, etc)*

YesNo
Referring Source Requirement*

VoluntaryCourt Ordered
Referral Source*
Referring Source Contact Name

First NameLast Name
Referring Source E-Mail
example@example.com
Referring Source Phone
Please enter a valid phone number.
Describe Relationship to Referring Source*
Treatment Time Requested*

90 Days180 Days
New Intake or Re-Admission*

New IntakeRe-Admission
Date Available to Start Treatment*

MonthDayYear
Date
If You Are Not Being Referred By An Agency, Please Provide A Reason For Seeking Treatment:*
Date of Last Use*
How Often Do You Use?*
Drug(s) of Choice*

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Emergency Contact Relationship*
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Insurance Information
Do You Have Medical Insurance?*

YesNo
Insurance Company Name*
Insurance Company Phone Number*
Please enter a valid phone number.
Insurance Card ID #*
Group ID #*
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Waiver To Release Application Status
Applicant Name*

First NameLast Name
Application Date*

MonthDayYear
Date
Authorization:

I hereby authorize NM Wellness to release information regarding my application status, estimated wait time, program acceptance, and intake for the purpose of collaboration and coordination of services to any affiliated facilities, my attorney, caseworker, Parole/Probation officer, Counselor, and family. I also authorize the following people to obtain my application status:
Please enter Name(s), relationship(s), email(s)and phone numbers below of people with authorization.*
Authorization:

I understand that NM Wellness cannot guarantee that the recipient will not disclose my application status to a third party. I understand that I can revoke my waiver at any time and for any reason. I understand that my Authorization will automatically expire one year from the date of my signature unless I request it be revoked earlier (see below). IF YOU ARRIVE AT YOUR CHECK-IN WITH ALCOHOL IN YOUR SYSTEM, YOU MAY BE TURNED AWAY. A COVID TEST WILL BE ADMINISTERED UPON ARRIVAL. A NEGATIVE COVID TEST RESULT WILL BE REQUIRED FOR ENTRY. By submitting this application, I approve NM Wellness and their affiliated facilities to disclose their company name when attempting to contact me
Signature*

Clear
Date*

MonthDayYear
Date
Transition Planning

New Mexico Wellness (NMW) is a non-denominational, residential alcohol and drug treatment campus situated on 10 acres in Rio Rancho, New Mexico. NMW has transformed the Felician Sisters Convent into a place of healing and recovery for those struggling with addiction.
Destination after discharge:*
Person's Full Name of Destination Discharge

First NameLast Name
Phone Number
Please enter a valid phone number.
If no discharge destination has been identified, I authorize NM Wellness to provide transportation or make arrangements for transportation to a mutually agreed upon location regardless of the reason for my discharge. I understand that I must notify NM Wellness if my discharge destination changes.
Signature

Clear
Date*

MonthDayYear
Date
Acknowledgment of Approved and Prohibited Items:

It is NM Wellness policy that any prohibited items are not allowed on property at any time without prior written approval from the Executive Director. Prior to admission, a thorough search of your person and property will be conducted. Possession of any of the prohibited items may result in revocation of your application and/or admission status. Possession of any prohibited items after the admission process is completed may result in your immediate discharge from the facility.
Approved Items Allowed Upon Admission:
- Pants/Jeans (up to 10)
- Sweat Pants (up to 10)
- Sweat Shirts (up to 10)
- Shirts (up to 10)
- Shoes (up to 3)
- Underwear (up to 10)
- Bras (up to 10)
- Jackets/Light sweaters (up to 3)
- Pajamas (up to 3)
- Shower Shoes (1) / Slippers (1)
- Robe (1)
- Belts (1)
- Hats (2)
- Towels (5)
- Washcloths (5)
- Undershirts (7)
- Art Supplies (alcohol-free)
- Face Masks
- Only store/restaurant / SEALED Food
- 30-day supply of all current medication and medical supplies
Non-Approved Items
- Cell Phones
- Personal Items
- No Home Cooked Food
- Nail Polish/Nail Polish Remover
- Hair Dye
- Hairspray (if alcohol is in the first 3 ingredients listed)
- Perfume (if alcohol is in the first 3 ingredients listed)
- Coconut Oil
- Straight Razors
- Sharpie Markers
- Bandanas
- DVD Players/Portable DVD Players
- Fire Stick, Roku, Google TV or any media streaming devices
- Sexually oriented materials and/or products
- Essential Oils
- Power Strips/3 way connectors
- Guns/Ammunition/Knives
- Pepper Spray
- Stun gun/Tasers
- Multi-use tools (Leatherman)
- Any item fashioned as a weapon
- Gaming Systems
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

NM Wellness Application

Your Information

Referral Information

Emergency Contact Information

Medical Insurance Information

Criminal Offense History

Medical History

Mental Health History

Waiver To Release Application Status

Authorization:

Authorization:

Transition Planning

Acknowledgment of Approved and Prohibited Items:

Approved Items Allowed Upon Admission:

Non-Approved Items