Peer-Run Respite Guest Recommendation Form

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.*
Guest Name *

First NameLast Name
Guest Legal Name*

First NameLast 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?*

yesno
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race/Ethnicity

African AmericanBlackAsianHispanic/LatinCaucasian - Not HispanicNative American/AlaskanMultiracialOther
Pronouns used
Are you vaccinated?

yesnoprefer not to answer
Which Covid Vaccine did you receive?

ModernaJohnson & JohnsonPfizerprefer not to answer
Did you receive a booster?

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

state identificationDrivers licensePassportMilitary ID Card
Have you received a mental health diagnosis or recently experienced emotional distress? (we do not need to know the diagnosis)*

yesno
Provider type/where is the person coming from?*

Group HomeEmergency RoomInpatient MedicalInpatient Mental HealthJailCSURespiteUnhousedLives on their own and or with familyUnknown
Do you have any accessibility needs?*

yesno
If yes, please explain
Do you have any dietary needs?*

yesno
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?*

yesno
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 NameLast 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?*

yesno
If yes, how long ago was it?

less than 3 months agoless than 6 months agoless than 9 months agoover a year
Have you used our mobile respite?

yesno
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

AcceptedNot AcceptedServices no longer neededUnable to reach
Should be Empty:

Peer-Run Respites

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:

Please note