Prosperity Clients

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

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

General Information

First Name *


Last Name *


Email *


Phone *

Preferred Pronouns

She/Her

He/Him

They/Them

Ze/Hir

Street

City

Zip Code

State

Service Information

Please select the services you are interested in receiving:

Health Services:

Affordable Care Act Marketplace (“Obamacare”)

Food Stamps/SNAP

Jackson Card

Medicaid

Cash assistance/TANF

Wealth Services:

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

Demographic Information

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-- Cis Man Cis Woman Non-binary / Gender fluid Trans man Trans woman Prefer not to answer

What is your preferred language? --None-- English Spanish Haitian Creole Other Prefer not to answer

Are you proficient in English? --None-- Yes No Prefer not to answer

What is your family's nationality? --None-- Bahamas Brazil Colombia Cuba Dominica Dominican Republic Ecuador El Salvador Guatemala Haiti Honduras Jamaica Mexico Nicaragua Peru Puerto Rico United States Venezuela Other Prefer not to answer

If the list above does not include the country you're looking for, type it in here:

What is your highest level of education> --None-- Elementary (Primary) Middle/ Jr. High High School Diploma GED Some College (1-4 years, no degree) Associates Degree Technical or Trade School Undergrad College Degree Graduate Degree Doctorate Degree 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's your current occupation?

What is your current living situation? --None-- Rent Own Living with family/friends Transient Houseless Other Prefer not to answer

In what type of housing do you currently reside in? --None-- Single-family home Apartment/Condominium Manufactured/Mobile home Townhouse Multi-family home/Duplex Efficiency/Accessory dwelling unit Other 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

Are you a veteran? --None-- Yes No Prefer not to answer

Do you identify as a person with a disability? --None-- Yes No Prefer not to answer

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.

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