Prescreening Questionnaire

Kitsap Homes of Compassion

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

1. Date:___________________
2. Print Name:____________________________
3. Date of Birth: __________________________
4. Contact phone:_________________________
5. Last time any drug or alcohol use? Please indicate the drug name. _________________________________________________________________________        _________________________________________________________________________

6. Have you been arrested for a felony in the last 3 years? If yes, the charge?

___________________________________________________________________

7. Have you been arrested for a misdemeanor in the last year? If yes, the charge?_______________________________________________________
8. Have you ever lived in a shared house before? If yes, when/where/with whom?_______________________________________________________
9. 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.

_____________________________________________________________

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

____________________________________________________________

11. 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?__________________________
12. Are you able to take care of yourself independently?_________________
13. Do you have a vehicle that will need to be parked? __________________
14. Are you aware that Kitsap Home of Compassion is an Affordable Home Program with a house or apartment home where the rooms are provided to mature program participants and the common areas of the house are shared by the house residents? And no pets 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 $400/mo program fee. (Higher fee for higher income or 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. Are aged 55+, or are disabled and aged 40+.

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

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