Guest Recommendation Form
Prefer not to answer
What is your date of birth? (month,day,year)
Have you received a mental health diagnosis or recently experienced emotional distress?
Do you have any accessibility needs?
If yes, please explain
Primary language spoken
Do you have any cultural or linguistic needs you’d like us to know about?
What city/town are you from?
How did you get connected to the peer respite?
Please enter your email address or phone number so we may get in contact with 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. *If you have pets, especially large dogs, they need to be contained in another room of your house while the peer support meeting is happening. *No chain smoking, drugging, or drinking during peer support meeting.
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