Get Support

Your journey to empowerment starts here, this is the first step toward the support and resources you need. We admire your courage in seeking assistance and are here to guide you toward a brighter future. Complete this form with hope, knowing that we're ready to help you and your family find stability and prosperity.

Together, let's embark on a path filled with promise.

Before Filling out the Form, Please note:

To be considered for the CityHouse program, applicants must meet the following criteria:

1. Applicants must be a current resident of Palm Beach County

2. Applicants must be at least 21 years old

3. Applicants must have no more than 2 children and children must be under the age of 8

4. Applicants cannot be currently pregnant

4. Applicants with a history of substance abuse must have at least a year of sobriety and actively working a recovery program

If you meet the above criteria please continue with the application for the CityHouse program. Thank you.

General Information

Today's Date

YYYY

Referred By:

Mother's Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth:

YYYY

Age

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

About You:

What is Your Current Living Situation?

Which County Are You Seeking Support In?

Education Level:

Current Employer:

What is Your Total Monthly Income?

Please List Any Other Sources of Income:

How Long Have You Been Employed?

What is Your Primary Source of Transportation?

Marital Status:

Health & Medical

Are You Pregnant?

If Yes, How Far Along Are You with Your Pregnancy?

Do You Have a Primary Care Physician?

If Yes, Please State the Name of the Physician.

Are You Currently Taking Medication?

If Yes, Please List Medications

Have You Been Hospitalized in the Past 12 Months?

If Yes, Please Explain Your Hospitalization

Do You Have a History of Substance Abuse?

If Yes, What Substances Have You Used in the Past Year?

Have You Ever or Are You Currently Experiencing Issues with Your Mental Health?

If Yes, Please Explain. Including any Treatments, Medications, or Baker Acts.

Spiritual & Family Life

Do You Attend Church on Weekly Basis?

If Yes, Please List the Name of the Church

How Many Children Do You Have?

Do You Have Full Custody?

First Child's Name:

First Name

Last Name

First Child's Date of Birth:

YYYY

Second Child's Name:

First Name

Last Name

Second Child's Date of Birth:

YYYY

Please List Any Additional Children Along with Their Date of Birth:

Are Your Children Enrolled in School or Daycare?

Please List the Name of the School(s) or Daycare(s).

Do Your Children Have a Primary Care Physician?

If Yes, Please State the Name of the Practice:

Are Your Children Taking Any Medications?

If Yes, Please List the Name of the Medications:

Your Story:

Please Share Your Story and the Situations Leading You to Become a Single Mother:

Where Are Your Children's Father(s)?

Does Your Children's Father(s) Have Visitation Rights? If Yes, Please Explain.

Why Do You Want to Participate in the CityHouse Program? What Do You Hope to Gain from Living at CityHouse?

Agreement & Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a resident, and false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. Please be advised that a drug and background screening will be asked and the outcome may prevent you from participating in the CityHouse program.

Do You Agree to the Terms & Conditions

Yes, I Agree

Our Policy:

CityHouse Delray Beach, Inc. is committed to providing equal opportunity in all participant's practices to all qualified applicants without regard to age, race, color, national origin, sex, handicap, disability, or any other category protected by Federal, State, or Local Law. The Civil Rights Act of 1964 exempts CityHouse Delray Beach, Inc., a religious organization, against discrimination in its program based on religion because CityHouse Delray Beach, Inc. is a religious organization. It establishes its policies, procedures, and philosophy of business on biblical principles.

Prefer to Send it Your Application? Click Here to Download a PDF Version.
Mail Your Application to: CityHouse Inc. PO BOX 8451 Delray Beach, FL 33482