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-- 305 Pink Pack 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 Jackson Health System 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 Overtown Connect/Aire Ventures SBDC @ FIU Self-Help Credit Union Startup FIU Sylvester Comprehensive Cancer Center Other

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

Required Information

Client's First Name *


Client's Last Name *


Client's Email *


Client's Phone *

Client's Preferred Pronouns *

She/Her

He/Him

They/Them

What is the client's preferred language? * --None-- English Spanish Haitian Creole

Household size, including the client *


Annual Household Income *

The client lives in Miami-Dade County. *

Client's Street *

Client's City *

Client's Zip Code *

Client's State *

Service Information

Please select the services the client is 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

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

Optional Demographic Information

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

When was the client born?

What race does the client 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 does the client identify with? --None-- Hispanic Non-hispanic Other Prefer not to answer

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

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

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

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

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

Submitting your form

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.
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*We use a special tax software that enables us to efficiently process tax referrals, which requires us to use a separate referral link. The link to refer a client for tax preparation services is here.
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"By submitting this request for services, I attest that the information I am providing is true and correct."