NM Wellness Application

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*

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Date*

MonthDayYear
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:*
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

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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)
- 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*

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Date*

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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:

Starter Kit

Non-Approved Items