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Thank you for your referral!
Thank you for your referral!
Thank you for your referral!
Please complete the following form.
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:
Is the Client a Baptist Health System patient?
--None--
Yes
No
I don't know
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, 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.)
--None--
Yes
No
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.
Select Language
English
Spanish
Haitian Creole