Thank you for your referral!

Please complete the following form.

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  Caro Fernandez-Mazzoni published this page in Financial & Health Services 2021-12-06 19:45:55 -0500

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

Preferred Pronouns

She/Her

He/Him

They/Them

Ze/Hir

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 you are interested in receiving:

Affordable Care Act Marketplace (“Obamacare”)

Food Stamps/SNAP

Jackson Card

Medicaid

Social Security Disability (SSI/SSDI)

Cash assistance/TANF

Budgeting

Credit Establishment

Credit Repair

Debt Management

FAFSA

Financial Goal Setting

Lending Circle

Other Financial Coaching/Capabilities services

Savings

Small Business Assistance:

Basic bookkeeping

Business credit

Business modeling

Incorporation

Loan applications

Marketing strategy

Permits

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.

*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.