Application – Registration Process

Guiding You Through Our Application Process

Darrin’s Place in Espanola, NM, is dedicated to providing recovery programs tailored to our client’s individual needs.

Man undergoing an interview with family support

Our Process

We want you to achieve a successful recovery. To determine the level of service needed, an assessment, a medical clearance, and a psychological evaluation may be completed prior to admittance. One of our staff members will assist you throughout the entire intake process. We ensure that we will walk you through every step of the way.

Get Started

We are here to help! If you are interested in any of our programs or services, you may call our intake coordinator at (505) 372-4511 or click on the Request for Services link below. You will never be denied services based on inability to pay. A discounted/sliding fee scale is available based on income and family size. We look forward to hearing from you soon.

Request For Services

APPLICANT INFORMATION

Your application is completely confidential. All information is stored in a secure environment and used only for purposes related to your admission and recovery program.

This practice serves all clients regardless of inability to pay. Discounts for essential services are offered based on family size and income. For more information, ask at our Front Desk or reach out to our Admissions Coordinator at 505-376-7288. Thank you.

Darrin’s Place Behavioral Health agrees to not discriminate in the provision of services to any individual based on the individual inability to pay; whether payment for those services would be made under Medicare, Medicaid, or CHIP; the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity will not be factors in the denial of an applicant. Darrin’s Place Behavioral Health will have a sliding/partial fee scale and application accessible to all applicants and provided through email, fax and, or in person. Darrin’s Place Behavioral Health Admission and Front Desk team will be knowledgeable of the Sliding/Partial fee scale to provide further details for applicants. ”

Treatment Length (please check all that apply)
- IOP (Requesting Community Housing on Site)
- IOP (No Housing Requested / Telehealth)
- 90 Days of Treatment
- 180 Days of Treatment
Name
First Last
DOB:
MM slash DD slash YYYY
Age:
Email:
Phone(Home):
Phone(Cell):
Phone(Other):
Street Address City State / Region ZIP / Postal Code
Gender
- Male
- Female
Veteran of the U.S. Military Services?
- No
- Yes
If yes, Branch:
Do you have a stable Internet connection?
- Yes
- No
Are you being referred by an Agency? (CYFD, Court Compliance, Hospital, Detox, etc.)
- No
- Yes
If yes, please provide agency contact information:
Select all that apply:
- New Intake
- Re-admission
- Voluntary
- Court Ordered
Contact Name
Referring Agency:
Phone
Email
If you are not being referred by an agency, please provide reason for seeking treatment:
Drug(s) of choice (to include alcohol and prescription drugs):*
Date of last use:
MM slash DD slash YYYY
Frequency of use:
Amount of each substance:
EMERGENCY CONTACT
Name
First Last
Phone
Street Address Address Line 2 City State / Region ZIP / Postal Code Country
MEDICAL INSURANCE
Insurance Company:
Phone
Address
Street Address Address Line 2 City State / Region ZIP / Postal Code Country
Insurance ID#
Group ID#
CRIMINAL OFFENSE HISTORY
Have you been or are you currently affiliated with any gang related activity?
- Yes
- No
Are you required to register as a sex offender?
- Yes
- No
Have you been convicted of a felony?
- Yes
- No
If yes, explain:
Have you been convicted of a misdemeanor?
- Yes
- No
If yes, explain:
Do you have any pending charges?
- Yes
- No
If yes, explain:
Applicant Signature:
Date:
MM slash DD slash YYYY
MEDICAL HISTORY
Do you currently have any medical conditions which require special care?
- Yes
- No
If Yes, please explain:
Are you currently on any medications?
- Yes
- No
If Yes, please explain:
Do you have any allergies and adverse reactions:
- Yes
- No
If Yes, please explain:
Do you have any current psychiatric and/or mental health medications?
- Yes
- No
If yes, please explain, including dose and frequency:
What is the highest level of education you have completed?
Were you ever diagnosed with a learning disability?
- Yes
- No
If yes, please explain:
Have you ever worked with a mental health provider (psychiatrist, psychologist, therapist)?
- Yes
- No
If yes, please explain:
Do you require an Oxygen tank?
- Yes
- No
If yes, please explain:
MEDICAL HISTORY CONTINUED
Current Height:
Current Weight:
Last Visit to primary care physician:
Have you ever been hospitalized?
- Yes
- No
If yes, please explain:
Have you or are you being treated for any of the following? Are you currently having symptoms related to any of the following?
- Asthma
- Sexual dysfunction
- Cancer
- Migraines, headaches
- Vision problems/loss
- Heart attack
- Pancreatic or gall bladder disease
- Thyroid problems
- Bleeding problems/easy bruising
- Dizziness
- HIV
- Sleep apnea
- Digestive problems
- Hearing loss or ringing in ears
- High or low blood pressure
- Head trauma
- Diabetes
- Heart conditions
- Urinary problems
- Hepatitis
- Stroke
- ulcers
- Hepatitis
- Gastric reflux or ulcers
- Allergies, seasonal or other
- Other
If yes to any of the above, please explain:
MENTAL HEALTH HISTORY
Personal mental health history (Check all that apply):
- Obsessive compulsive disorder
- Anger
- Post-traumatic stress disorder
- Attention deficit disorder
- Depression
- Anxiety/Panic attacks
- Suicide attempts
- Alcohol addictions
- Psychosis/Schizophrenia
- Other Addictions
- Mania or Bipolar disorder
- Drug addictions
- Learning disabilities
- Other
If yes to any of the above, please explain:
WAIVER TO RELEASE APPLICATION STATUS
APPLICANT NAME:
APPLICATION DATE
MM slash DD slash YYYY
I hereby authorize Darrin’s Place to release information regarding my application status. This authorization of release includes my application approval, estimated wait time, program acceptance, and intake for the purpose of collaboration and coordination of services.
I authorize the following people to obtain my application status:.
Name
Relationship
Name
Relationship
Name
Relationship
Name
Relationship
I Disclosure: I understand that Darrin’s Place 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).
Signature:
Date:
MM slash DD slash YYYY
TRANSITION PLANNING
Darrin’s Place 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, Darrin’s Place request that clients identify a safe discharge destination and a person who is supportive of his/her recovery.
Destination after discharge:
Person’s Name
Phone
If no discharge destination has been identified, I authorize Darrin’s Place 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 Darrin’s Place if my discharge destination changes.
Signature:
Date:
MM slash DD slash YYYY
ACKNOWLEDGMENT OF APPROVED AND PROHIBITED ITEMS
It is Darrin’s Place 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 sweater (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
Darrin’s Place reserves the right to change the list above as necessary for the safety of our staff and clients.
Applicant Signature:
Date:
MM slash DD slash YYYY

Guiding You Through Our Application Process

Our Process

Get Started

Request For Services

APPLICANT INFORMATION

Treatment Length (please check all that apply)

Select all that apply:

EMERGENCY CONTACT

MEDICAL INSURANCE

CRIMINAL OFFENSE HISTORY

MEDICAL HISTORY

MEDICAL HISTORY CONTINUED

MENTAL HEALTH HISTORY

WAIVER TO RELEASE APPLICATION STATUS

TRANSITION PLANNING

ACKNOWLEDGMENT OF APPROVED AND PROHIBITED ITEMS

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