In order 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.

program application

Select a date

Referred By

Mother's Name

Phone

Age

Birthday

Current Address

What is your current living situation?

Education Level

Employer

How long have you been employed?

What is your primary source of transportation?

Marital Status

Are you pregnant?

If yes, how far along are you with your pregnancy?

Do you have a primary physician?

If yes, please state name of 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 treatment, medication or Baker Acts.

Do you attend church on a weekly basis?

If yes, please list the name of the church.

Please list all sources of income.

Total Monthly Income

How many children do you have?

Do you have full custody?

First Child's Name

Date of Birth

Second Child's Name

Date of Birth

Please list additional children names along with their date of birth.

Are your children enrolled in school or daycare?

Please list the school(s)/daycare.

Do your children have a primary care physician?

If yes, please state name of practice.

Are your children taking any medications?

If yes, please list medications.

Please explain what situation occurred for you to have become a single mother?

Where are your children father(s)?

Does your children's father(s) have visitation rights? If so, please explain.

Why do you want to participate in the CityHouse program? What do you hope to gain from living at CityHouse?

Agreement and 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.

I agree to the terms & conditions

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.

Thank you for submitting an application for the CityHouse Residential Program. A family advocate will be reaching out to you at the contact information provided in your application as soon as possible.

You can print and mail your application to

PO BOX 8451

Delray Beach, FL 33482

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