Thank you for your referral!

Please complete the following form.

REFERRAL INFORMATION

Name of Person making the Referral


Email of person making the Referral


Organization Affiliation
--None-- Baptist Follow Up Clinic/Homestead Community Health Clinic Baptist Health System - Other Baptist Health System - South Miami Hospital Baptist Health System - West Kendall Baptist Hospital Borinquen Health Care / Medical Center Chase Bank (Community Partners) City of Miami CM Internal CM Social/Comms DCFCU (Rise Fund) FIU Education Effect FIU NeighborhoodHELP Hialeah Housing Authority (HHA) Homestead Police Department Legal Services of Greater Miami Le Jardin Miami Dade College Homestead TRIO Miami Dade College Single Stop Hialeah Miami Dade College Single Stop Kendall Miami Dade College Single Stop North Miami Dade College Single Stop Padron Miami Dade College Single Stop West Miami Dade College Single Stop Wolfson Miami-Dade County Miami Workers Center Mission Asset Fund Neighborhood Housing Services of South Florida Opa Locka CDC Other Overtown Connect/Aire Ventures SBDC @ FIU Self-Help Credit Union Startup FIU

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

DEMOGRAPHICS INFORMATION

Client's First Name


Client's Last Name


Client's Email


Client's Phone


Client's Zip Code


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

Client's Preferred language
--None-- English Spanish Haitian Creole Other Prefer not to answer

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)
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.)
--None-- Yes No

Is the Client a Baptist Health System patient?
--None-- Yes No I don't know

Please share any additional details that will assist us in processing this intake (best time to contact client, special accomodations, etc).

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. If the client hasn'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 the client is also interested in assistance with tax preparation, please click here to request an appointment.