Soteria Guest Recommendation Form

Soteria Guest Recommendation Form

If you need assistance filling out this form, please feel free to call (575) 291-7030
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
2 digit month, 2 digit day, 4 digit yearDate
Are you filling this recommendation out for yourself or on behalf of someone you are 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 with us before?
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?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you experiencing any of the following?
Is there any additional context you would like to provide, or something else you are experiencing that isn't captured on the list above?
Have you ever received a diagnosis related to psychosis?
What would feel most helpful right now?
Is there anything else that would be helpful?
Do you feel that your experiences are related in any way to...
Are you looking for support on any of the following?
Kiva Centers' Agreement:

At Soteria, 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 compromise the sanctity of our shared environment, I may be asked to leave.
Agreement
Primary Language:
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?
If no, please explain:
Where are you coming from?
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.Format: (000) 000-0000.
Do you currently have a guardian?
If the answer is yes, please enter the Guardian's phone number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance

The following section relates specifically to insurance. The reason we ask the following questions is because Kiva Soteria bills services directly through New Mexico Medicaid Providers. Not having insurance through NM Medicaid does not disqualify you from the support offered at Kiva Soteria. We just want to know how to bill services and if you are willing to enroll in NM Medicaid during your stay.
Do you currently have health insurance through Medicaid?
If the answer is yes, which Medicaid Provider are you currently insured with?
If the answer is no, are you willing to begin the application process for New Mexico Medicaid?
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?
Race / Ethnicity
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 Soteria. Please note that Soteria program is subject to availability at the time of enrollment. * All information collected is confidential and is used to better understand the demographics we support. *Recommendation forms are reviewed within 24 hours of receipt Mon-Fri 10am-4pm. No recommendations are reviewed on the weekends or major holidays.
Should be Empty:

Soteria Guest Recommendation Form

Insurance

Please Note