Metropolitan Assessment & Treatment Services(MATS)

Bernalillo County Department of Substance Abuse Programs(DSAP)

Metropolitan Assessment & Treatment Services(MATS)

Mariposa (UNM Milagro)

5901 Zuni SE Albuquerque NM 87108

PROGRAM APPLICATION

[PLEASE PRINT CLEARLY]

______

Applicant Name: Last First Middle Application Date

NOTE: Please submit all required documentation and answer all items fully. Incomplete applications will not be reviewed.

Information is used for consideration of program acceptance and placement. All pages with the exception of this cover

pagewill be destroyed for any non-accepted application. Please be aware that background reviews are performed on every

applicant and that any information obtained may be considered in acceptance eligibility.

FOR INTERNAL OFFICE USE ONLY PLEASE DO NOT WRITE IN BOX

Demographic Data

Your Date of Birth:
______
MONTH DAY YEAR / Your Race/Ethnicity:
Your Social Security #: / Your Primary language:

English Spanish Other: ______
Biological Gender:

Male Female / Who referred you to this program:
Self Turquoise Lodge Hospital

Santa Fe Recovery UNM - Milagro Other
Your Contact Number: ______

May we leave a message for you at this number: Yes No / Who is your current insurance provider:

None Blue Cross Blue Shield Molina Healthcare

Presbyterian Health Plan United Health Care Other

Physical and Mental Health Data

When is the due date for current pregnancy: / Do you currently have a UNM Milagro Counselor: Yes No
Are you currently linked into the UNM Milagro Yes No
program for prenatal care: / Do you currently face any mental health issues: Yes No
Do you currently face any physical health issues: Yes No
(Other than your pregnancy) / Do you currently take medication to maintain a mental health issue:

Yes No
Do you currently take medication to maintain a physical health issue:

Yes No / Do you have access to all medication used to maintain a mental health issue:
N/A Yes No
Do you have access to all medication used to maintain a physical health issue:
N/A Yes No / When was your last mental health exam:
(Use N/A if you have never had one)
month / year ______

Substance Use and Treatment Data

What substance has been your primary drug of choice?
______/ When did you last enter treatment for substance abuse care?
month / year ______
How many years would you say that you have been addicted to some form of drug/alcohol:
#: ______/ What program did you last receive treatment from for substance abuse care?
Program name: ______
In the last 5 years, how many times have you been in an outpatient program for substance abuse treatment:
#: ______/
Did you fully complete the program listed above: Yes No N/A
In the last 5 years, how many times have you been in an inpatient program for substance abuse treatment:
#: ______/ What is your goal related to substance use:

Drugs: Abstinence/No use at all Cut Down/Controlled Use N/A

Alcohol: Abstinence/No use at all Cut Down/Controlled Use N/A

Legal & Service Agency Involvement Data

Do you currently have an open court case / pending charge:

Yes No / Do you currently have a warrant, restraining order, or protective order:

Yes No
Are you currently on any type of supervision (Probation, Parole, Pretrial Services, Community Custody, etc.):
Yes No / Do you have an open case/order for child support payment:

Yes No
Do you have an open case with CYFD:

Yes No / Are you currently receiving or set up to receive services with any other agency:

Yes No

Housing / Living Situation Data

If you were to attend this program, do you have a safe and stable home environment available after completion:
Yes No / In the last 12 months, How often were you without a stable living arrangement:

None 1 – 90 days 91- 180 days 181- 270 days 271 – 365 days
Have you ever participated in government based housing services (City, County, State, Federal, etc.):
Yes No / In the last 12 months, have you used any of the homeless shelters for overnight housing:

Yes No
Have you ever lived in a group based sober living program:
Yes No / What are your desired goals regarding your living arrangement:

Live with relatives/significant other Sober living home Find own housing

Relational & Community Support Data

Do you currently have person(s) in your life that will be able to assist you with caring for your new baby:
Yes No / Your Relational Status: [CHECK ONE]
No Relationship In committed relationship In relationship with complication
Do you currently have person(s) in your life that would support in transporting you to appointments, job searches, etc.:
Yes No / Have you given birth to other children:
Yes No
If yes, Current Age (s): #1: ______#2: ______#3: ______#4: ______#5: ______

Do you have physical custody of any listed children: Yes No
Have you ever used a support group sponsor to maintain recovery from addiction or for help with other life issues:
Yes No
Have you ever used a church group to maintain recovery from addiction or for help with other life issues:
Yes No / Sexual Orientation: [CHECK ONE]

Bisexual Heterosexual Homosexual
Do you have any conditions that hinder you from being housed in a community based setting with other individuals receiving similar care:

Yes No / Do you currently deal with issues related to physical. emotional, or sexual abuse that makes it difficult for you to exist in a community setting with others:

Yes No

Employment and Finance Data

Are you legally able to work in the state of New Mexico:

Yes No / In the last 12 months, how many months were you working in a job in which you received a check and paid taxes: [CHECK ONE]

None 1-3 months 4-6 months 7-9 months 10-12 months
Do you face any barriers that prevent you from obtaining a job or working:
Yes No / Do you currently receiveany income from a source other than employment:

Yes No
If you were to attend this program, do you believe that you would be able to find employment within 90 days
Yes No / Do you currently have any outstanding debt to a utility company (PNM; NM Gas; Cell phone company):

Yes No
Do you currently have an active bank account in the state of New Mexico:
Yes No / Do you currently have any outstanding debts, wage garnishments, or legal judgements that affect or could potentially affect you being employed:

Yes No

Personal Statement

DSAP Revised 7/2015