Anemoni Initial Questionnaire

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– Step 1 of 12

This form includes questions and information we usually talk about by phone, video chat or in person during an initial conversation to explore whether or not Anemoni supports are a good fit for you right now.

This is being offered in writing because you have requested that as an accommodation. If you already filled out the short form, there may be a few questions that repeat here. We apologize for the inconvenience of being asked to answer the same thing twice. That should only be true in a couple of places.

We may still want to check in briefly after reviewing this, but this will help keep that shorter.

If at any point, you change your mind and would like to speak to someone directly, please call Anemoni house to let us know so we can set a time to do that with you. The house number is 413-538-4100.

We highly recommend that you CLICK HERE and check if we have space at Anemoni House or Anemoni Mobile Supports or on our wait list.

If we do not have space on our wait list then we are not able to review new requests.

A Few Things Before You Get Started:

What happens with the answers you provide here?: This process is intended to help you and Anemoni team members determine if Anemoni supports are a good fit for you right now. Most answers here will not be entered into any sort of file for you and won’t be made available to anyone beyond yourself and Anemoni team members.

However, there are a few pieces of information that we are asking specifically because our primary funder (the Massachusetts Department of Mental Health) requires us to submit enrollment forms with a little bit of information on them about the person who is enrolling.

This means that if you do end up staying at Anemoni House or being supported through Anemoni Mobile Supports, we will use those pieces of information on an “enrollment form”. (If you do not end up staying at the house or connected to mobile respite, no information about you will be given to DMH at all.) Each question that is asking you for information that may be used on a DMH form will be clearly marked with **.

Please note that we will not be checking your ID and so you can use a chosen or nick name, etc. If there is a required question that you don’t feel comfortable answering, you can put N/A.

If you’ve already filled out the ‘Initial Support Request’ form, some of these questions will be repeats. We have repeated them here because – on occasion – someone might be filling this out without having first filled out the request form. Please answer all repeat questions, even if you’ve answered them before.

What can I expect after I’ve filled this out? We make team-based decisions. That means whether or not you are a fit for Anemoni supports right now is a decision that will be made by you and at least two Anemoni team members.

How long this process takes depends a bit on when you are filling this out. If you’re filling it out between the hours of 11am and 8pm, we should usually be able to review it and get back to you within a couple of hours.

If you’re filling it out between 8pm and 11am, it may take a bit longer as we aren’t always able to review these responses during the overnight and earlier morning.

If you feel like it’s been too long, you can call the house to check in. The house number is 413-538-4100.

Your first name (Can be a chosen name, doesn't need to match your ID)** *

Your first name (Can be a chosen name, doesn't need to match your ID)**

Pronouns you want us to use for you (They/them, she/her, he/him, Ze/Zir, etc.)

Gender? ** *

Race? ** *

Ethnicity ** *

Date of Birth ** *

Preferred Language ** *

English
Spanish
American Sign Language
Other

Phone (If no phone, put all 5's) *

Can we text AND call this number? *

You can text AND call me at this number.
Just texts, please. (NO CALLS)
Just calls, please. (NO TEXT)

Can we text/leave detailed messages at this number? *

Yes, you can leave detailed texts and/or voicemails.
You can leave a quick message, but no details.
Please do not leave messages at this number.

E-mail (Put N/A if no e-mail) *

What's the best way to reach you? *

Call me
Text me
E-mail me
Any of the above

In what town or city are you currently living and/or staying? *

Have you ever stayed at Afiya peer respite or used Anemoni supports before? (Check all that apply) *

I have stayed at Afiya House before (Northampton, MA)
I have stayed at Anemoni House before (Holyoke, MA)
I have been supported through Anemoni Mobile Supports before
I have stayed at another peer respite (outside of Wildflower/Western Mass)
I have never stayed at a peer respite before

When was your last stay at Afiya House (Northampton, MA) *

Less than 6 months ago
6 months to a year ago
Over a year ago

When was your last stay at Anemoni House (Holyoke, MA) *

Less than 6 months ago
6 months to a year ago
Over a year ago

When were you last supported through Anemoni Mobile Peer Respite? *

Less than 6 months ago
6 months to a year ago
Over a year ago

What other peer respite (outside of Wildflower's peer respites) have you stayed at before? When was your stay? *

Any concerns about any of your prior experiences with peer respite that you want to share?

There are four basic requirements you must meet in order to be considered for support through Anemoni peer respite.

These include:

You are 18 years of age or older
You are trans, queer or otherwise a part of the LGBTQ+ community
You live or are staying in Massachusetts
You are not registered as a Level 3 Sex Offender*

*While we fully believe everyone deserves support, the sex offender registry system requires addresses to be publicly listed when someone who is considered to be a ‘Level 3 sex offender’ is staying somewhere, including at peer respite. Unfortunately, being listed in this way puts Anemoni at too great a risk at this time.

Please let us know below if you meet all four of these basic requirements: *

Yes, I am 18+ AND I am trans/queer/LBGTQIA+ AND I am living or staying in MA AND I am not registered as a Level 3 sex offender.
I meet all the requirements, EXCEPT I live outisde of MA. However, I’m very close to the border and would still like to be considered.
No, I do not meet one or more of these requirements.

NOTE: When we say ‘trans/queer/LGBTQIA+’ we are saying that anyone who holds an identity that fits under the LGBTQIA+ umbrella is included. This includes people who are agender, asexual, no gender, pansexual, intersex and more.

We’re sorry that you do not currently meet one or more of the requirements to be considered for support through Anemoni.

Here are some other supports to consider:

If you are outside of Massachusetts and interested in peer respite, check out this listing of peer respites in other areas.

If you are in Massachusetts, but not trans, queer or otherwise a part of the LGBTQ+ community and are still interested in peer respite, you may want to check out Afiya House or Kiva’s peer respites.

We also welcome people under 18, in any part of the world, etc. to join our on-line supports. Learn more about Wildflower’s on-line supports here.

If you think you’re getting this message in error and would still like to be considered, please call Anemoni House directly. The house number is 413-538-4100.

Personal Please did

We know there are many reasons why someone might want to have some support in filling this out. However, we also want to make sure that – if someone is helping you – that your answers here still represent what you want and not someone else’s ideas.

Are you filling this out yourself or is someone else helping you? *

I’m filling it out by myself.
I’m writing the answers, but I have someone here who is helping me think through what to write.
Someone else is filling out the form/writing my answers for me.

We understand that supporters can be helpful for a number of reasons.

However, sometimes we have found that people have felt pushed/ceorced/forced by their supporters (often in well-intended ways) to try different resources and services.

It’s very important to us that, if someone is seeking support through Anemoni, that it is 100% voluntary.

Is it your choice to seek Anemoni supports? *

Yes, this is 100% my choice. My supporter is just here to help me.
My supporter suggested this, but it is something I want to do.
I’m not sure if this is something I want to do.
This really isn’t something I want to do. Someone else told me I should.

Are you interested in staying at Anemoni House or Mobile Peer Respite Support? *

I want to stay at Anemoni House.
I want support through Anemoni Mobile Support.
I prefer Anemoni House, but might be interested in Mobile Support if the house is full
Not sure yet

PLEASE NOTE: Because you said you’re not sure yet, we are providing information on both Anemoni House and Anemoni Mobile Peer Respite below.

Below is some basic information about Anemoni House.

It is intended to make sure you know what the house is and what it offers so you can make an informed decision about whether or not it meets your needs.

Please check off ALL items once you have read them. *

Anemoni House is a 5 bedroom house based in Holyoke, MA. 3 bedrooms are on the first floor (wheelchair accessible) and 2 are on the second floor.
Stays at Anemoni House are usually up to 2 weeks long.
It is intended for trans, queer and other LGBTQIA+ community members who are 18+, in MA and navigating significant emotional distress, problems with substsances, etc.
Everyone who works at Anemoni has navigated personal struggles and been trained to use the wisdom gained through that experience to support others on similar paths.
Peer-to-peer support is available 24/7 as needed.
All bedrooms are private and have a bed, desk, dresser and TV, as well as a locked box in the closet to store personal items.
Art supplies, books, a computer, etc. are also available.
One bedroom will be prioritized for people who are recovering from Gender Affirming Surgery.
Each person is able to lock their own bedroom door using a code they set when they arrive.
There are also multiple common spaces (2 living rooms, 2 kitchen areas, a library, etc.) available to everyone at the house.
A washer and dryer are available on both the first and second floors.
Food is available with at least some meat and vegetarian options, but you are welcome to bring your own food if you have specific things you want to have on hand.
Our food budget is limited. If you have very specific food preferences or dietary restrictions/allergies, we encourage you to bring the items you need.
People are generally expected to make their own meals, though sometimes people will decide to make a meal together and in some instances, a team member might cook.
People are generally expected to be able to manage dressing, using the bathroom, any medical needs, etc (with some exceptions for people recovering from surgery).
If you have a friend, family member, PCA, etc. who helps you, they are welcome to visit you at the house to help you as needed as long as they respect other people’s privacy.
The house is very near a bus stop and also has a driveway and on street parking available for people with cars.
Anemoni is within reasonable walking distance of a market, convenience store, Dunkin Donuts and pharmacy. Various gas stations, a library, etc. are also short car rides away.
Service animals are welcome, but we aren’t able to accommodate emotional support animals at this time.
Children and partners are welcome to visit, but are not able to stay with you at the house.
Everyone is asked to clean up after themselves and to keep smoking outside in designated areas.
People are asked to leave by noon on their last day to allow us time to get the room ready for the next person.
People leaving the house may be able to sign up for Anemoni Mobile Supports if a spot is available and they’re interested in some transitional support.
A weekly support group for people who’ve stayed at the house will also soon be available ongoing.

Do you have any questions about any of these things?

Below is some basic information about Anemoni Mobile Support.

It is intended to make sure you know what Mobile Support is and what it offers so you can make an informed decision about whether or not it meets your needs.

Please check off ALL items once you have read them.

Anemoni Mobile Support works with people wanting support while still staying in their own homes or other environments outside of Anemoni House.
It is intended for trans, queer and LGBTQIA+ community members who are 18+, in Western MA and navigating significant emotional distress, problems with substances, etc.
The Anemoni Mobile Support team (our Bridgers) can support up to 8 people before going to a wait list.
Anemoni Bridgers have all navigated personal struggles and been trained to use wisdom gained through that experience to support others on similar paths.
The majority of support is provided remotely (phone, text, on-line), but support can also be available in person as needed and makes sense.
The main focus of Anemoni supports involve talking, not being alone and similar. However, Mobile Supports can also include exploring resources, advocating at an appointment, filling out paperwork for benefits and more.
In order to stay enrolled in Anemoni Mobile Supports, support must be offered at least once every 48 hours.
People enrolled in Anemoni Mobile Supports should expect to be supported by at least a few different Bridgers since no one Bridger works every day.
Where meetings happen will be negotiated by the Bridger and person they’re supporting based on needs, wants and time available.
There are some limits on where Bridgers may go (if an environment seems hostile due to others present, etc.).
Contact will typically include at least a daily check-in, but the overall amount of time per day will be determined by the wants and needs of the person being supported and time available. However, this won’t typically be over 2 to 3 hours total (including all texts, calls and/or in person meetings).
An overnight line is also available for people enrolled in Anemoni Mobile Support for urgent support needs.
Mobile Support is generally available for up to 30 days.

Do you have questions about any of these things?

We do our best to minimize the risk of spreading illness through our respites and when offering support in the community.

Have you been sick or around someone sick recently? *

I am not sick and have not been around anyone who has been sick recently.
I am not sick, but someone else close to me has been sick recently.
I have been sick recently.
I am currently still sick.

Did that person test positive for COVID? *

Yes.
No.
Not sure.

Did you test positive for COVID? *

Yes.
No.
I didn’t test, so I’m not sure if it was COVID.

How long ago was that?

If someone was recently sick or shows sign of getting sick, we may ask them to wear a mask when around others. *

I am fine wearing a mask if I’ve been sick or start showing signs of getting sick.
I’m not sure how I feel about wearing a mask, even if I’ve been sick/show signs of getting sick.
I am NOT okay with wearing a mask.

On occasion, someone else may ask people to mask as an accommodation request. (For example, if they have a weakened immune system.) *

I am okay masking in common spaces/vehicles if someone else requests that as an accommodation for their health needs.
I am not sure how I feel about this.
I am NOT okay masking even if someone else has made that request as an accommodation for their health needs.

PLEASE NOTE: We generally use scent free products when cleaning. However, if we know someone has been sick recently, we may temporarily use stronger products to help kill germs and prevent spreading of illness. Please check below to acknowledge that you have read this statement. *

I understand that scent free cleaning products will normally be used, but stronger products may temporarily be used if there’s been a recent illness.

In this section, we are hoping to learn a bit more about you, what’s going on right now and why you’re interested in Anemoni Peer Respite.

Please don’t feel required to share anything you’re uncomfortable sharing.

How did you hear about Anemoni? *

Did anyone tell you to reach out to us? *

No, I made the decision to reach out myself.
Yes, someone told me I should reach out to Anemoni.

What did they tell you about Anemoni and why you should call? *

Can you share a bit about what's going on? (Specifically, what's going on that is leading you to want peer respite support?) *

Where are you staying right now? ** *

I’m at home.
I’m staying at a group home/Group Living Environment (GLE).
I’m staying with friends or family.
I’m being held in a locked psychiatric facility.
I’m in an Emergency Room at a hospital
I’m in a clinical respite or crisis stabilization unit.
I’m in a homeless shelter, living in a motel or similar.
I’m unhoused and living outside/in a tent
I’m in a facility for addiction/substance use treatment
I’m in a jail or other detention facility
I’m in a nursing home
Other

You marked 'Other'. Please share a bit more about where you're staying. *

You said you're being held in a locked psychiatric facility. Why are you interested in peer respite support after leaving there? *

I need ‘step down’ support to help me transition back to the community.
They won’t let me leave unless I have somewhere to go and/or a plan for support in place.
The place I am in right now isn’t working for me and/or is making things worse. I need to find somewhere else to go and/or other support.
I’m not sure.

You said you are staying at a clinical respite or crisis stabilization unit. Why are you interested in peer respite after you leave? *

My time is running out here and I need somewhere else to go.
I need ‘step down’ support to help me transition back to community.
I’m being threatened with a locked unit/psychiatric force unless I find somewhere else to go and/or another plan for support.
They won’t let me leave unless I have somewhere to go and/or a plan for support.
The place I’m in right now isn’t working for me and/or is making things worse. I need to find somewhere else to go and/or another plan for support..
I’m not sure.

Can you say more about what hasn't worked for you there? *

How are you thinking Anemoni supports might be different or work better for you? *

If you were to get support through Anemoni, what are some things you are hoping to work on? (Can be as simple and broad as getting some rest/clearing your head or as focused as looking into different housing options and getting help to fill out applications, etc. It's also okay to say you don't know/aren't sure.) *

If you stay at Anemoni House, where will you go after your stay ends? *

Home
Group home/Group Living Environment (GLE)
Family or friends
Homeless shelter
Back to living on the street, in a tent or similar
Not sure
Other

You said 'Other' regarding where you will go after your stay at Anemoni House ends. Please explain below. *

Do you have a service animal that would be coming with you to Anemoni House or when out with a Bridger for Mobile Peer Respite? *

Yes, I have a service animal that is with me at all times.
No, but I have an emotional support animal.
No, I do not have any animals that would be coming with me.

Reminder: Unfortunately, we are not able to accommodate emotional support animals at Anemoni House.

Some Bridgers may be able to accommodate emotional support animals in their cars, but this will need to be discussed and negotiated ahead of time.

Service animals are always welcome.

Please just be reminded that we do ask that you keep your service animal with you and under your control at all times.

On rare occasions, people have brought service animals that bark in an ongoing and disruptive manner and/or act aggressively toward other animals and/or humans.

Unfortunately, when that happens, we are not able to accommodate the service animal.

If you stay at Anemoni House, do you require a first floor bedroom? *

Yes, I use a wheelchair or have other mobility limitations and need a first floor bedroom.
It’s not an absolute requirement, but it’s hard for me to get up and down stairs.
First and second floor bedrooms are fine.
I actually have a preference for second floor if possible.

Do you have any other accommodation requests?

Anemoni House strives to be scent free as much as possible. We ask people working and staying at the house to also avoid using scented products. We make scent free shampoo, conditioner and laundry detergent available at the house. *

I understand that, if I stay at Anemoni House, I will be asked to avoid scented products (shampoos, conditioners, perfumes, etc.)

Our Values

Anemoni is a part of Wildflower Alliance and that means we also operate under the same values.

Specifically, Wildflower has ‘Definining Principles’ that everyone is asked to help uphold. (This includes people working, being supported or otherwise a part of our community.)

You can see our full Defining Principles statement HERE.

We will summarize the Principles here and ask that you review them.

RESPECT:

We aim to offer respect, kindness, and compassion toward others and their belongings.
We focus on inclusive and respectful language.
Shows of gratitude and appreciation for one another are encouraged.
It is important to respect differences of opinion, beliefs, culture, appearances and ways of life.
We are committed to interrupting words and actions that are rooted in racism and other injustices when we see them happening.

Please check below to acknowledge you have read the summary of the 'Respect' principles listed above. *

I have read the ‘RESPECT’ principles summarized above and understand that I will be asked to be a part of upholding these values.

Self-determination & Personal Strength

People get to make meaning out of their own experiences and choose their own paths through life.
People are the experts of their own experience.
Rule-setting is avoided as much as possible.

Please check below to acknowledge you have read the summary of the 'Self-determination & Personal Strength'' principles listed above.

I have read the ‘SELF-DETERMINATION & PERSONAL STRENGTH’ principles summarized above and understand that I will be asked to be a part of upholding these values.

Potential for Change

Each person has tremendous potential for growth and healing.
Everyone deserves compassion when they are struggling.

Please check below to acknowledge you have read the summary of the 'Potential for Change' principles listed above. *

I have read the ‘POTENTIAL FOR CHANGE’ principles summarized above and understand that I will be asked to be a part of upholding these values.

Genuine Human Relationships

We prioritize real and meaningful connections.
Respecting each other’s physical, sexual and personal limits is important.
Imperfection is an expectation.
Our relationships are impacted by biases that we need to actively work to become aware of and unlearn.

Please check below to acknowledge you have read the summary of the 'Genuine Human Relationships' principles listed above. *

I have read the ‘GENUINE HUMAN RELATIONSHIPS’ principles summarized above and understand that I will be asked to be a part of upholding these values.

Mutuality

Mutuality means a focus on the connections between us.
There are no ‘fixers’ and people being ‘fixed’ within our community.
Each of us has the potential to move, question, change, act, teach, lead, and share.
We seek out opportunities to raise up marginalized voices.

Please check below to acknowledge you have read the summary of the 'Mutuality' principles listed above. *

I have read the ‘MUTUALITY’ principles summarized above and understand that I will be asked to be a part of upholding these values.

Healing Environments

Privacy is respected.
We strive to make spaces as accessible as possible.
The impact of trauma on our lives is real.
Conflicts are addressed directly whenever possible, and are valued for the learning opportunities they can often provide.
We are committed to creating environments that acknowledge and work to undo all types of systemic oppression.
We all have responsibility for caring for the spaces we hold within our community.

Please check below to acknowledge you have read the summary of the 'Healing Environments' principles listed above. *

I have read the ‘HEALING ENVIRONMENTS’ principles summarized above and understand that I will be asked to be a part of upholding these values.

We’re almost done!

This section goes over some things that could be a reason why we would have to end a stay at Anemoni House or discontinue offering Anemoni Mobile Supports.

Specifically, it’s important to know that the following could result in supports being ended:

Bringing weapons to Anemoni House or an interaction with an Anemoni Bridger*
Taking or intentionally damaging things that don’t belong to you
Using racial, gender-related and other slurs or continuing to express harmful ideas based on race, gender, disability, etc.
Actively (intentionally) refusing to use someone’s correct names and/or pronouns
Bringing drugs/alcohol to Anemoni House or in a vehicle with a Bridger and/or showing up to Anemoni House or mobile supports high or drunk, particularly if in a disruptive way**
Leaving the house and staying out for 24-hours or more without communication *OR* not showing up/responding to attempts to offer connect and offer support for 48-hours or more when enrolled in mobile respite.
Any other consistent disregard for Wildflower’s Defining Principles

*We understand that people who are unhoused may sometimes carry knives with them out of necessity and we may be able to store items of this nature, provided someone lets us know they have it and works with us on keeping it locked up.

**We understand some people use drugs/alcohol as a normal part of getting through the day. We can work with people on this, provided they do their best to minimize smell of alcohol/drugs in common spaces (particularly when someone else says they’re working on avoiding alcohol/drugs) and that it does not lead to other disruptions.

Please check below to acknowledge that you have read through some of the reasons why Anemoni supports would be ended. *

Yes, I have read through this list of reasons of why support through Anemoni may be ended.

Last page!!!

We know this has been a lot of information and if a lot of it is new to you, then it’s probably a lot to think about, too.

Please use these last few questions to let us know where you’re at.

Based on all this information, do you think Anemoni is a good fit for what you need/want right now? *

Yes, I am confident its a good fit.
I’m still not sure and would like to talk about it more/ask some questions.
No, I think it’s probably not the right fit.

Do you have any lingering questions you're hoping we can answer or anything else you want us to know?

Okay, thanks for letting us know you don’t think it’s a good fit right now.

We recommend you still click ‘SUBMIT’ so your answers get recorded. That will mean we’ll be able to access your answers in case you change your mind.

If you change your mind in the next week or two and want to move things forward, send us an e-mail at info@wildfloweralliance.org or call Anemoni House and we can look your answers up so you don’t have to re-do this whole form! The house number is 413-538-4100.

You can also check out some of our other supports below:

Wildflower’s On-line Supports
Wildflower’s In Person Supports

This is a lot to consider and we get why might still have some questions and/or be unsure if this is a good fit.

We know that going through this form was a lot of work and we appreciate your sharing what you have so far.

If you have specific questions, let us know in the ‘lingering questions’ box and we can call or e-mail you with answers as soon as we’ve had a chance to review.

Otherwise, even though you’re still thinking it over, we’ll go ahead and review your responses overall and see if we have any questions for you and if it’s seeming like a good fit on our end.

If you submitted this between the hours of 11am and 8pm, we will do our best to review this and get back to you within two hours. If it’s between 8pm and 11am, it might take a little longer.

If you feel like it’s been too long, please reach out to us by calling Anemoni House. You can also e-mail info@wildfloweralliance.org.

Okay, thanks for letting us know you think Anemoni supports are a good fit for what you need/want!

We know that going through this form was a lot of work and we appreciate your sharing what you have.

If you submitted this between the hours of 11am and 8pm, we will do our best to review this and get back to you within two hours. If it’s between 8pm and 11am, it might take a little longer.

If you feel like it’s been too long, please reach out to us by calling Anemoni House. The house number is 413-538-4100. You can also e-mail info@wildfloweralliance.org.

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