Karaya Respite
Guest Recommendation Form
Guest Name
*
First Name
Last Name
Guest Legal Name
*
First Name
Last Name
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?
*
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?
*
How would you like us to contact you? (phone/text/email)
*
Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Relationship to you
*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.
Submit
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