Mobile Peer Run Respite Guest Recommendation Form

Which mobile peer-run respite location are you interested in*

Guest Name (Legal Name)*

First NameLast Name

Pronouns used

Race/Ethnicity

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your date of birth? (month,day,year)*

Have you received a mental health diagnosis or recently experienced emotional distress?*

yesno

Do you have any accessibility needs?*

yesno

If yes, please explain

Primary language spoken*

Do you have any cultural or linguistic needs you’d like us to know about? *

Recommended by: *

How did you get connected to the peer-run respite?*

Please select below which in-person meeting option works best for you.*

Visit me at homeMeet me at a local place (for example: cafe, library)Would like to discuss another option

Please enter the best phone number or email address for us to make our initial point of contact with you.*

May we leave a detailed message at the phone number or email listed?*

yesno

If you would prefer to connect with someone over the phone or through text messaging, please consider one of the following options:

The Behavioral Health Help Line (BHHL) is available 24/7, 365 days per year and is available for all residents of Massachusetts. Visit the website to chat online.

https://www.mass.gov/info-details/behavioral-health-help-line-bhhl-faq

Call or text 833-773-2445.

988 & Crisis Systems Response: Providing 24/7, free and confidential support to people in suicidal crisis or emotional distress works. The Lifeline helps thousands of people overcome crisis situations every day.

https://www.samhsa.gov/find-help/988/faqs

Call or text 988

Kiva Centers Peer Support Line: Available Monday through Friday from 8:00pm to 12:00am Eastern Standard Time. Our phone line is staffed by trained peer support specialists who have personal experience with mental health challenges. Whether you need someone to listen, offer guidance, or just provide a friendly voice, our team is here to support you. You don’t have to go through this alone – call the Kiva Centers Peer-Run Support Line today.

https://kivacenters.org/

Call 508-688-5898

Mobile Peer-Run Respite

Please complete the following form to request an in-person mobile peer-run respite visit with a Kiva Centers' Peer Support Worker.