Karaya Guest Recommendation Form

Karaya Respite

Guest Recommendation Form
Guest Name *

First Name Last Name
Guest Legal Name *

First Name Last Name
Please list the phone number, text number or email address you would like us to use to communicate with you. *
Gender

Male Female Non-Binary Prefer not to answer
Biological sex assigned at birth

Male Female Prefer not to answer
Pronouns used
What is your date of birth? (month,day,year) *
Do you have a legal form of identification? *

state identification Drivers license Passport Military ID Card
Have you received a mental health diagnosis or recently experienced emotional distress? (we do not need to know the diagnosis) *

yes no
Do you have any accessibility needs? *

yes no
If yes, please explain
Do you have any dietary needs? *

yes no
If yes, please explain
Primary language spoken *
Do you have any cultural or linguistic needs you’d like us to know about? *
Do you have any allergies? *
If you choose to take medication, do you feel safe to self administer it? *

yes no
If no, please explain
What city/town are you from? *
Please describe your current living arrangements *
Is there anything else you would like us to know before checking in?
Recommended by: *
How did you get connected to the peer respite? *
Provider type/where is the person coming from? *

Group Home Emergency Room Inpatient Medical Inpatient Mental Health Jail CSU Respite Homeless Lives on their own and or with family Unknown
Emergency Contact *

First Name Last Name
Email
example@example.com
Relationship to you
Have you been a guest with us before? *

yes no
If yes, how long ago was it?

less than 3 months ago less than 6 months ago less than 9 months ago over a year
Have you used our mobile respite?

yes no
*It is suggested that this document be completed by the individual who is being recommended to be invited as a Kiva Peer Run Respite Guest *Recommendations are not limited to DMH *Please note that Karaya Peer Respite is subject to availability at the time of enrollment.
For Karaya Staff only

Accepted Not Accepted Services no longer needed Unable to reach
Should be Empty:

Karaya Respite