Prosperity Clients

Thank you for your interest in Catalyst Miami's services! Please complete the following form.

Required Information

First Name *


Last Name *


Email *


Phone *

Preferred Pronouns *

She/Her

He/Him

They/Them

What is your preferred language? * --None-- English Spanish Haitian Creole

Street *

City *

Zip Code *

State *

Service Information

Please select the services you are interested in receiving:

Affordable Care Act Marketplace (“Obamacare”)

Food Stamps/SNAP

Jackson Card

Medicaid

Cash assistance/TANF

Budgeting

Credit Establishment

Credit Repair

Debt Management

Financial Goal Setting

Other Financial Coaching/Capabilities services

Savings

Small Business Assistance:

30-minute Intro Consultation

Basic bookkeeping

Business credit

Business modeling

Incorporation

Loan applications

Marketing strategy

Permits

Optional Demographic Information

To understand why we collect all of this data, please click here.

When were you born?

What race do you identify with? --None-- American Indian or Alaska Native Asian Black or African American Indigenous (Non-Native American) Native Hawaiian or Other Pacific Islander White Multiracial Other Prefer not to answer

What ethnicity do you identify with? --None-- Hispanic Non-hispanic Other Prefer not to answer

What gender do you identity with? --None-- Male / Cis Man Female / Cis Woman Non-binary / Gender fluid Trans man Trans woman Prefer not to answer

What is your employment status? --None-- Full-time Part-time Contract Disability Furloughed Retired Seasonal/Temporary Self-employed Student Unemployed Volunteer Prefer not to answer

What is your current health insurance status? --None-- Insured Uninsured/No health insurance Jackson Card/Jackson Charity Care Do not know Prefer not to answer

What is your current marital status? --None-- Single Married Divorced Separated Widowed Domestic Partnership Prefer not to answer

Please share any information you think might help us better serve you (for example, best time to contact you, any special accomodations you need, or a brief information about your services needs)*


After you click Submit, you will receive an email with next steps. We will contact you as soon as possible. If you haven't heard back from us within a week, please send an email to [email protected], or call us (or text us) at (786) 744-5079.

*If you are also interested in assistance with tax preparation, please click here to request an appointment.

By submitting this intake form, you are OPT-IN and are consenting to receiving SMS text messages from Catalyst Miami for appointments, events and general outreach purposes at any time while inquiring about or receiving services. Message frequency may vary. You may reply STOP to opt-out of future messaging at any point. Reply HELP for more information. Message and data rates may apply.

We do not rent, lease, or sell customer lists or any data collected on our site to third parties. Catalyst Miami does not sell, share, or lease personal information with third parties for marketing/promotional purposes.

Click here to see our Privacy Policy.