NM Wellness Veterans Application
You have served your country and now we would be honored to serve you.
Our team is committed to providing the best of clinical care for issues connected to alcohol, opioids, fentanyl, and most other substances.
To make the process as efficient as possible please complete the following application and be sure to include your TriWest Insurance information. All information is received and stored on a secure site for complete confidentiality.
Preferred Location
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Rio Rancho, NM
Taos, NM
Either Location
Please note we can not guarantee location choice selection but will do our best to accommodate you.
Your Information
Name
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First Name
Last Name
Email
*
example@example.com
Best Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date Of Birth
*
Age
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Gender
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Male
Female
Other
Social Security Number
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Veteran Of The U.S. Military?
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Yes
No
Branch of Military
Do You Have A Stable Internet Connection?
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Yes
No
Your Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Referral Information
Are You Being Referred By An Agency? (CYFD, Court Compliance, Hospital, Detox, etc)
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Yes
No
Referring Source Requirement
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Voluntary
Court Ordered
Referral Source
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Please Select
Self
Family/Friends
Legal System
Other
Referring Source Contact Name
First Name
Last Name
Referring Source E-Mail
example@example.com
Referring Source Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Describe Relationship to Referring Source
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Treatment Time Requested
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30 Days
60 Days
90 Days
180 Days
New Intake or Re-Admission
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New Intake
Re-Admission
Date Available to Start Treatment
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-
Month
-
Day
Year
Date
If You Are Not Being Referred By An Agency, Please Provide A Reason For Seeking Treatment:
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Date of Last Use
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How Often Do You Use?
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Drug(s) of Choice
*
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Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
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Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Medical Insurance Information
Do You Have Medical Insurance?
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Yes
No
Insurance Company Name
*
Insurance Company Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Card ID #
*
Group ID #
*
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Criminal Offense History
Have You Been Or Are You Currently Affiliated With Any Gang Related Activity?
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Yes
No
Are You A Registered Sex Offender?
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Yes
No
Have You Been Convicted Of A Felony?
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Yes
No
If Yes, Please Explain
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Have You Been Convicted Of A Misdemeanor?
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Yes
No
If Yes, Please Explain
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Do You Have Any Pending Charges?
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Yes
No
If Yes, Please Explain
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Signature
*
Date
*
-
Month
-
Day
Year
Date
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Medical History
Have You Experienced Any Seizure Activity Within The Last 12 Months?
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Yes
No
Are You Pregnant
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Yes
No
If Yes, Explain:
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Do You Require Any Special Diets?
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Yes
No
If Yes, Explain:
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Do you currently have any medical conditions which require special care?
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Yes
No
If Yes, Explain:
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Are you currently on any medications?
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Yes
No
If Yes, Explain:
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Do you have any allergies and adverse reactions:
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Yes
No
If Yes, Explain:
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Do you have any current psychiatric and/or mental health medications?
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Yes
No
If yes, please explain, including dose and frequency:
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What is the highest level of education you have completed?
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Were you ever diagnosed with a learning disability?
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Yes
No
If yes, please explain.
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Have you ever worked with a mental health provider (psychiatrist, psychologist, therapist)?
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Yes
No
If yes, please explain.
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Do You Require An Oxygen Tank?
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Yes
No
If yes, please explain.
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Current Height:
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Current Weight:
*
Last Visit Date to Primary Care Physician:
Have You Ever Been Hospitalized?
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Yes
No
If yes, please explain.
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Have you or are you being treated for any of the following? Are you currently having symptoms related to any of the following? (Check all that apply)
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None
Asthma
Migraines, Headaches
Pancreatic or Gall Bladder Disease
Dizziness
Digestive Problems
Head Trauma
Urinary Problems
Ulcers
Allergies, Season or Other
Sexual Dysfunction
Vision Problems/Loss
Thyroid Problems
HIV
Hearing Loss or Ringing In The Ears
Diabetes
Hepatitis
Cancer
Heart Attack
Bleeding Problems/Easy Bruising
Sleep Apnea
High or Low Blood Pressure
Heart Conditions
Stroke
Gastric Reflux or Ulcers
Other
Insomnia
If yes to any of the above, please explain:
*
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Mental Health History
Personal mental health history (Check all that apply):
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None
Obsessive Compulsive Disorder
Depression
Psychosis/Schizophrenia
Learning Disabilities
Anger
Anxiety/Panic Attacks
Other Addictions
PTSD
Suicide Attempts
Mania or Bipolar Disorder
Attention Deficit Disorder
Alcohol Addictions
Drug Addictions
Other
If yes to any of the above, please explain:
*
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Waiver To Release Application Status
Applicant Name
*
First Name
Last Name
Application Date
*
-
Month
-
Day
Year
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
*
Date
*
-
Month
-
Day
Year
Date
Transition Planning
NM Wellness is an Intensive Outpatient Treatment center providing evidence based and person-centered drug and alcohol rehabilitation treatment. Our evidence-based treatment program promotes a long term sobriety lifestyle which includes transition planning as soon as treatment is initiated. For this reason, NM Wellness request that clients identify a safe discharge destination and a person who is supportive of his/her recovery.
Destination after discharge:
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Person's Full Name of Destination Discharge
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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
Date
*
-
Month
-
Day
Year
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)
Cell Phones (1)
Robe (1)
Belts (1)
Hats (2)
Towels (5)
Washcloths (5)
Undershirts (7)
Musical Instruments Ex: Drums (1-2)
Art Supplies (alcohol-free)
Face Masks
30-day supply of all current medication and medical supplies
Starter Kit
Basic Hygiene Items-Shampoo, Conditioner, Soap, Guarded Razors, Shaving Cream, and Feminine hygiene products (alcohol must not be listed in the first 3 ingredients)
One carton of cigarettes
Non-Approved Items
Outside Food or Drinks
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
*
Date
*
-
Month
-
Day
Year
Date
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Submit
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