Peer-Run Respites
Guest Recommendation Form
Please note: this jotform will no longer be in use starting 4/3/2024. Please use this link to apply for our peer-run respite services instead:
Click Here to Apply to Peer Run Respite (New Form)
Please select which Peer-Run Respite you are applying for.
*
Please Select
Karaya(located in Worcester)
Juniper(located in Bellingham
La Paz(Located in Dudley)
no preference
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. Please list at least two ways for us to communicate with you.
*
First way to contact
*
Second way to contact
Is it ok to leave a detailed message at the number listed?
*
yes
no
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
African American
Black
Asian
Hispanic/Latin
Caucasian - Not Hispanic
Native American/Alaskan
Multiracial
Other
Pronouns used
Are you vaccinated?
yes
no
prefer not to answer
Which Covid Vaccine did you receive?
Moderna
Johnson & Johnson
Pfizer
prefer not to answer
Did you receive a booster?
yes
no
prefer not to answer
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
Provider type/where is the person coming from?
*
Group Home
Emergency Room
Inpatient Medical
Inpatient Mental Health
Jail
CSU
Respite
Unhoused
Lives on their own and or with family
Unknown
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 to food or medication, etc
*
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?
Where do you plan to go after your stay with us?
*
Recommended by
*
Name and Position
Phone number
How did you get connected to the peer-run respite?
*
Emergency Contact
*
First Name
Last Name
Email or Phone Number
*
example@example.com
Phone number and or email address
*
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
Please note
*We will contact you or the person who made the recommendation at least 3 times. Please be aware of this. *It is suggested that this document be completed by the individual who is being recommended to the Peer-Run Respite. *Recommendations are not limited to DMH. *Please note that the Peer-Run Respite is subject to availability at the time of enrollment. * All information collected is confidential and is used to better understand the demographics we support in Massachusetts. *Recommendation forms are reviewed within 24 hours of receipt Mon-Fri 10am-4pm. No recommendations are reviewed on the weekends or major holidays.
For Staff only
Accepted
Not Accepted
Services no longer needed
Unable to reach
Submit
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