Apply Here!

To qualify you must be homeless or housing unstable, make below 50% of Kitsap County's median income (approx. $40,000/year), and be a person with a mental health need and/or have used substances in the past or present (including alcohol, cannabis, illegal drugs, etc.).

I certify that:

I am homeless or housing unstable
Yes (sheltered)Yes (un-sheltered)No

My household makes below 50% of Kitsap County's median income of approx. $40,000/year
YesNo

If you answered NO please tell us your approximate yearly income

I am a person with mental health need and/or have used substances in the past or present (including alcohol, cannabis, illegal drugs, etc.)
Mental HealthSubstance UseBothYes, prefer not to specifyNo

Do you have Medicaid (Apple Health)?
YesNo

Are you currently homeless (sheltered or unsheltered)?
Yes (sheltered)Yes (unsheltered)No

Your current address (or where you are currently sleeping)

Monthly Income

Source(s) of Income (examples; SSI, SSDI, employer, none, etc.)

Social security number

Criminal History (list all felonies, and any misdemeanors from the past 3 years)

Substance Use (describe your history with drugs & alcohol, include date of last use)

Reference Name (someone who knows you well)

Relationship (how do they know you?)

Reference Phone number

Emergency Contact

Relationship (how do they know you?)

Contact phone number

Driver's license number/State ID number

Do you have a car?
YesNo

If yes enter Make, Model, Year: