Kitsap Homes of Compassion
Affordable Home Program Seeker Questionnaire (Women’s or Men’s homes)
- Print Name:____________________________
- Date of Birth: __________________________
- Contact phone:_________________________
- Last time any drug or alcohol use? Please indicate the drug name. _________________________________________________________________________ _________________________________________________________________________
- Have you been arrested for a felony in the last 3 years? If yes, the charge?
- Have you been arrested for a misdemeanor in the last year? If yes, the charge?_______________________________________________________
- Have you ever lived in a shared house before? If yes, when/where/with whom?_______________________________________________________
- 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.
- Have you recently had or have any upcoming surgical procedures? If yes, please explain.
- 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?__________________________
- Are you able to take care of yourself independently?_________________
- Do you have a vehicle that will need to be parked? __________________
- 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. _______