NM BON Diversion Program History and Assesment

NM BON Diversion Program History and Assesment

6301 Indian School RD NE Ste 701 Albuquerque, NM 87190 Office: 505.841.9091 Email : nmbon.diversion@bon.nm.gov
History and Assessment

If questions do not apply type in NA
License number*
Name*

First NameLast Name
Date of Birth*
Address*

Address

Address Line 2

CityState

Zip Code
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number and extension
Please enter a valid phone number.
Email address (no work emails)
example@example.com
List any other names that you have used*
List any other Licsense you have
Employment History
Current Job Status*

EmployedSuspendedTerminatedLeave with payLeave without payResignedOther
Job title/position*
Current Employer*
Address Of Current Employer*

Street Address

Street Address Line 2

CityState

Zip Code
Shift/Hours*
Phone number of current employer*
Start date of Current employer
Current Supervsor/Manager*
Current Supervisor/Manager Phone*
Medical Leave Available?*

yesnoOther
Who is your Health Insurance?*
Any Recommendation made from your employer?
Did your employer refer you to the Diversion Program*

yesno
Tell us how your job performance has been affected*
Describe any previous employment problems*
Previous Employer
Name of Previous Employer *
Previous Job Title/Position
Address of Pevious Employer

Street Address

Street Address Line 2

CityState

Zip Code
How long were you employed at your previous employer?*
Describe your reason for leaving ? *
Nursing Experience/Licensure
How Many years of expirence has a nurse?*
List all Areas of your Nursing Experience*
What other Type of Professional License do you hold?*
Highest Education Level*

LPNDiplomaADNBSNMSNDNPCRNAPHdNPCNPOther
Health History
Gender: How do you identify?*

WomanNon-binaryManPrefer to self-desribe, belowprefer not to answer
Self-describe:
Describe any Chronic Medical Conditions, injuries, pain, other *
Any Hospitlizations within the last five years? List Dates and diagnosis*
Current Medications, Include OTC*
Nature of The Problem (choose all that apply)*

Prescription medicines such as pain pills, stimulants, or anxiety medsOpiatesAmphetaminesCocaineHallucinogensMethamphetaminePCPDrugs From Work placeDivertingAlcoholPhysicalPsychological/Mental HealthOther: describe below
Describe other from above
Currently Being Treated*

yesno
Describe Treatment Include Type (inpatient) (outpatient), by who, how long, current *
Relapse?*

yesno
Details of Relapse
Substance Abuse History. Include drug of choice, Amount used, Frequency, First used, Last used*
How do you obtain the substance/Drug?*
Last Time you used substance/drug*
Amount*
Physical Manifestations appearance, symptoms, motor dysfuntion, blackouts, etc*
Emotional Manifestations depression, despair, aloneness, guilt/shame, anger, confusion, etc*
What is your perception of the problem right now?*
Who Knows about the problem? *
Has anyone talked with you about the problem before?*
Previous Diversion Involvemet
Have you been involved in a Diversion Program/Alternative to Discipline Program?*

yesno
Describe any other involvement. when, where, length, disposition, etc*
How were you referred to the NM Diversion Program*

Self-referralComplaintBoard Action
Past Criminal History
Do you have any Past, Current, or Pending Criminal/Felony charges or legal issues, arrest, convictions*

yesnopending
Please Describe (from above)*
Are you currently partcipating in court-ordered/pre-prosecution, drug court, probation programs.

yesnopending
Describe explain the program, charges, dates, state/location, dispositions, name of probation officer/case manager and phone number*
Family History
Marital Status*

singlemarrieddivorcedseperatedwidowedother
Living Situation: Live withn*

selfspouse/partner.significant otherchildrenparentsOther
Number of children and ages*
Self-History
Please describe any family history of SUD and or mental illness*
Describe any use of recreational drugs what types, last time used, how ofte, how much*
Describe any type of eating disorders*
Describe any work-related or school issues/problems*
Describe any history of trauma, abuse, neglect, victim or natural or other disasters*
Do you have now or expirenced in the past*

sleep problemsnightmaresappetite/eating problemslow energyhigh energysexual problemsdifficulty with concentrationdifficulty remmebering thingsdepressionpanic attacksanger Issueshallucinationstobacco usesuicidal thoughtspast suicide attempts
Each box you checked please give precise details *
Additional Comments
I have reviewed and understand the following, located on the New Participant site:
1. NM NURSING PRACTICE ACT, Diversion Program §63.21.29 NMSA
2. The Diversion Brochure
By digitally signing below, I attest that all the information provided in this webform is true, accurate, and complete to the best of my knowledge. I understand that any false or misleading information may result in consequences as determined by applicable laws and regulations. I acknowledge that the digital signature is my legally binding electronic signature for this document
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NM BON Diversion Program History and Assesment

History and Assessment

Employment History

Previous Employer

Nursing Experience/Licensure

Health History

Previous Diversion Involvemet

Past Criminal History

Family History

Self-History