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Please complete the following form.

Name of Person making the Referral


Email of person making the Referral


Organization Affiliation


If you marked "Other" in the previous field, please share your Organization Affiliation:


Is the Client a Baptist Health System patient?

















Client's Preferred Pronouns
She/Her
He/Him
They/Them
Ze/Hir

Client's Preferred language


If you marked "Other" in the previous field, please share the client's preferred language:


Please select the services the client is interested in receiving:
Credit-building & Coaching
Financial Coaching (e.g., financial goals and planning, disaster planning)
Tax Preparation
Public Benefits Enrollment (e.g. Food Stamps/SNAP, TANF)
Health Care Access (e.g. Medicaid, Obamacare/healthcare.gov, Jackson Card, etc)
Small Business Technical Assistance (e.g., counseling, assistance applying for loans, filing business taxes and annual reports, reviewing commercial leases and insurance policies, etc.)

Does the Client need assistance with any services not listed above? (Housing, transportation, technology access, etc.)


Please share any additional details that will assist us in processing this intake


Thank you for being Catalyst Miami's referral partner! We will begin processing this intake as soon as possible. The Client should expect to receive a phone call from our Intake Staff within 3 business days.