• NM BON Alternative to Discipline Program Intake Form

    6301 Indian School RD NE, Ste 701, Albuquerque, NM 87110 Office: 505.841.9091 Email : AlternativeToDisciplineProgram@bon.nm.gov

  • Once you begin the intake form, you must complete it in its entirety, as you will not be able to return to edit or modify your responses after submission.

  • Response Checklist

    Submit a Response within 20 days of receipt of Alternative to Discipline offer following a complaint
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Substance Use Disclosure Agreement

    REQUIRED: Please Answer the Following Questions
  • I acknowledge that I may have a substance use disorder and/or concerns related to the use of drugs, prescription medications, and/or alcohol.*
  • I am voluntarily requesting admission into the Alternative to Discipline Program for nurses with substance use disorders and agree to complete all admission requirements within two weeks.*
  • I understand that I am required to enter treatment for substance use disorder within the next two weeks, with a minimum level of care of intensive outpatient treatment or inpatient treatment.*
  • I acknowledge that I have reviewed and understand the requirements of the New Mexico Board of Nursing Alternative to Discipline Program.*
  • Alternative to Discipline Program Request - select one of the following options:*
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  • How were you referred to the NM Board of Nursing Alternative to Discipline Program*

  • Employment History

  • Current Job Status*
  • Format: (000) 000-0000.
  • Start Date of Current Employer
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Medical Leave Available?*
  • Did your employer refer you to the Alternative to Discipline Program?*

  • Previous Employer

  • Nursing Experience/Licensure

  • Highest Education Level

  • Health History

  • Gender : How do you identify?*
  • Current Medications, Include OTC*
  • Nature of The Problem (choose all that apply)*
  • Are you currently being treated?*
  • Relapse?*

  • Previous Diversion/Alternative to Discipline Program Involvement

  • Have you previously participated in a Diversion Program or Alternative to Discipline Program?*
  • How were you referred to the NM Alternative to Discipline Program?*

  • Criminal History

  • Have you ever been arrested, charged, convicted, or are you currently involved in any pending criminal matter or other legal issue?*
  • Are you currently participating in any court-ordered, pre-prosecution, or diversion program/ATDP, including drug court, probation, or a similar program?*

  • Personal, Family, and Living Information

  • Marital Status*
  • Living Situation

  • Family History and Background

  • Do you currently experience, or have you previously experienced, any of the following? (check all that apply)*

  • I acknowledge that I have reviewed and understand the following documents available on the New Participant site:

    • New Mexico Nursing Practice Act – Alternative to Discipline Program (§ 63.21.29 NMSA)
    • Alternative to Discipline Program Brochure

    By digitally signing below, I certify that all information provided in this webform is true, accurate, and complete to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in consequences as provided by applicable laws, rules, and regulations. I further acknowledge and agree that my digital signature constitutes my legally binding electronic signature for this document.

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