2025 Mobile Peer Run Respite Guest Recommendation Form

Guest Name*

First NameLast Name

Legal Guest Name (if different)

First NameLast Name

Pronouns used

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Do you have any cultural, linguistic, lived experience, or accessibility request you would like us to be aware of? (For example, would you prefer a peer support worker with experience in domestic violence, parenting, or another specific area? Do you need support in a particular language, such as Spanish)

How did you hear about our mobile peer support?*

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

Are there any safety concerns at our meeting location that we should be aware of? For example, could there be interruptions from others in the home, the presence of firearms or illicit substances, environmental hazards, or pets that might pose a risk?*

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

2nd contact method

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

YesNo

Race/Ethnicity (select all that you identify with)

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 a home/community visit from a Kiva Centers' Peer Support Worker.