Peer-Run Respite Guest Recommendation Form

Peer-Run Respite Guest Recommendation Form

If you need assistance filling out this form, please feel free to call 508-751-9600
Guest Name*

First NameLast Name
Guest Legal Name (if different)*

First NameLast Name
What are your pronouns? (for example, she, he, they)
Date of Birth*

MonthDayYear
Date
Are you filling this recommendation out for yourself or on behalf of someone you are supporting?

For myselfFor someone I am supporting
If filling out for someone else, what is your name and relationship to the person you are recommending for peer run respite?
Please note that our policy is to first reach out directly to the potential Guest. If we do not receive a response within 24 hours, we will follow up with a courtesy call to the Recommender to assist in establishing contact with the potential Guest.
Have you been a Guest at any of our respites before?*

YesNo
If yes, how long ago was it?

less than 3 monthsless than 6 monthsless than 9 monthsless than 12 monthsOver a year or longerN/A
Have you used our mobile peer run respite before?*

YesNo
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 Contact Method
Second Contact Method
Is it okay to leave a detailed message at the number listed?*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am living in Massachusetts but I don't currently have a legal address
Have you received a mental health diagnosis or recently experienced emotional distress? (we do not need to know the diagnosis)*

YesNo
Are you looking for support on any of the following? (Please note, our model is to provide peer and emotional support. We help Guests understand the local community resources available, but we do not provide case management services. Guests are responsible for making their own appointments, filling out their own applications etc. Not all of the services listed below, for example housing, legal aid, are provided directly by Kiva Centers. )

HousingObtaining IDLegal AidCourt & Parole SupportFood AssistanceSupport around Government Assistance such as DTA, SSDI, SSI etc.Grief SupportEmployment SupportObtaining Health Insurance or other insurance advocacyDepartment of Children and Families (DCF) navigationAdvocacy around Legal GuardianshipVisa / Immigration SupportClothingGender Affirming Care / Peer SupportSubstance Use RecoveryFuneral Assistance (Financial)Other Advocacy / Resource Needed Not Listed
Kiva Centers' Peer Run Respite Service Agreement:

At Kiva Centers, we offer a space of warmth and understanding for Guests seeking solace and support. We embrace the values of self-determination, reciprocity, safety and respect, as we strive to foster a home where all people are valued.

As I complete this Recommendation form, I pause to consider my own readiness to contribute positively to our shared space. Am I in a mental state that aligns with the principles of respect and dignity for fellow Guests, staff, and the land we gather on? I recognize the gravity of this responsibility, and I commit to upholding these principles in my actions.

I acknowledge that if I am not able to uphold these values or compromises the sanctity of our shared environment, I may be asked to leave or no longer be eligible for peer-run respite support in the future.
Agreement*

I affirm my commitment to contributing positively to the healing environment at Kiva Centers, to respect other Guests, staff, our home and the land we reside on and to uphold all values and policies. I acknowledge that as a voluntary service, I may leave at anytime and equally, Kiva Centers reserves the right to end my stay early.
Primary Language:

EnglishSpanishASLNot Listed
Do you have any cultural or linguistic needs?
Do you have any allergies (to food, medications, cleaning products etc) we should know about?
Do you have any dietary restrictions or preferences?
Do you have any accessibility accommodations you need?
Do you have any medical issues / symptoms that may impact your safety or experience that we should be aware of during your stay? (such as seizure history, loss of balance, slurred speech, nodding off etc.)
If you choose to take medication, do you feel safe to self administer it?*

YesNo
If no, please explain:
Provider type/where is the person coming from? (Please note, this question does not impact how quickly someone may be accepted to stay with us.)*

Lives on your own / with familyGroup HomeEmergency RoomInpatient MedicalInpatient Mental HealthJailCrisis Stabilization Unit (CSU)RespiteDomestic Violence Shelter / HomeShelterUnhoused (Living on the street with no shelter)UnknownOther - Not Listed
Please describe your current living arrangements:
Where do you plan to go after you stay with us?
Emergency Contact*

First NameLast Name
Emergency Contact's Relationship to You
Emergency Contact Phone Number*
Please enter your emergency contact's phone number.
Are you vaccinated against COVID-19?

YesNoPrefer not to answer
Which COVID vaccine(s) have you received?

Johnson & JohnsonModernaPfizerN/A
Is there anything else you would like us to know before checking in?
In this next session, we're going to ask you some questions about you, such as your age, race, and gender. These questions help us get the funding we need to continue running our homes and making our programs better.

Your personal information is kept stictly confidential. When we report on the data, we don't use any names or identifying information; we compile all the data into statistics.

You don't have to answer any questions you don't want to, and it won't change whether you can stay with us or not. It's totally up to you!
Gender Identity
Do you identify as part of the LGBTQ+ community?

YesNo
Race / Ethnicity

Asian / Asian-AmericanAlaskan NativeIndigenousBlackHispanic or LatinPacific Islander / Hawaiian NativeWhiteNot Listed
Have you ever served in the US Military?
Age Range
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.
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Peer-Run Respite Guest Recommendation Form

Please Note