Questionnaire

Prescreening Questionnaire
For Prospective Participants

Kitsap Homes of Compassion

Affordable Home Program Seeker Questionnaire (Women’s or Men’s homes)

  1. Date:___________________
  2. Print Full Print Name:____________________________
  3. Date of Birth: __________________________
  4. Contact phone:_________________________
  5. Last time any illegal drug or alcohol use? Please indicate the drug name. _________________________________________________________________________        _________________________________________________________________________
  1. Have you been arrested for a felony in the last 3 years? If yes, the charge?

___________________________________________________________________

  1. Have you been arrested for a misdemeanor in the last year? If yes, the charge?_______________________________________________________
  2. Have you ever lived in a shared house before? If yes, when/where/with whom?_______________________________________________________
  3. Do you have any physical disabilities that would prevent you from going up steps or stairs or completing a daily chore? If yes, please describe.

_____________________________________________________________

  1. Have you recently had or have any upcoming surgical procedures? If yes, please explain.

____________________________________________________________

  1. Do you want to reside in a private room or are you able to share a room with one other person if no private room is available?__________________________
  2. Are you able to take care of yourself independently?_________________
  3. Do you have a vehicle that will need to be parked? __________________
  4. Are you aware that Kitsap Homes of Compassion is an Affordable Home Program with a house or apartment home where the rooms are provided to individuals with disabilities and the common areas of the house are shared by the house residents? And no pets are allowed. _______

REQUIREMENTS FOR ACCEPTANCE INTO THE PROGRAM:

1. Verifiable steady income of at least $700/mo. (i.e.; SSDI, SSI), and can pay a minimum of $500/mo program fee. (Higher fee for private room or larger room)

2. Are currently homeless (living in a car, tent, homeless shelter, or temporary housing).

3. Have no violent crime record in last 3 years.

4. Not on the sex offender list.

5. No illegal drug use in last 9 months. Illegal drugs strictly prohibited.

6. If you don’t drink, we have sober homes. If you drink in moderation, we have Lower Barrier Homes.

7. Healthy enough to live independently. (Able to cook, clean, wash yourself, etc.) Some of our properties have stairs.

 

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