Prosperity Clients

Thank you for your interest in Catalyst Miami's services! Please complete the following form.

Basic Information

First Name *


Last Name *


Email *


Phone *

Preferred Pronouns *

She/Her

He/Him

They/Them

What is your preferred language? * --None– English Spanish Haitian Creole

Preferred Method of Contact

Email

Phone Call

SMS Text

Street *

City *

Zip Code *

State *


Catalyst Miami's programs and services aim to prioritize those with an income that falls at or below the income level indicated in the chart below.
Given your family size, does your income fall at or below the amount on the chart below? *
Your answer to this question will not guarantee or prevent your participation in our programming.
--None-- Yes No

Service Information

Please select the services you are interested in receiving: *

Affordable Care Act Marketplace (“Obamacare”)

Food Stamps/SNAP

Jackson Card

Medicaid

Cash assistance/TANF (applying as a Public Benefit through the DCF portal; Catalyst Miami doesn't offer direct cash assistance.)

Budgeting

Credit Establishment

Credit Repair

Debt Management

Disaster Matched Savings Program

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

Worker-Owned Business

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

Demographic Information

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

What race do you 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 do you identify with?* --None-- Hispanic Non-hispanic Other Prefer not to answer

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

When were you born?

What is your current health insurance status? --None-- Insured Uninsured/No health insurance Jackson Card/Jackson Charity Care I don't know Prefer not to answer

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

Household size, including yourself


Annual Household Income

Optional Screening and Referral to Partner Nonprofit Organization Beyond the Bars

Do you have a criminal record? --None-- Yes No

Are you looking or have you looked for work through temp agencies? --None-- Yes No

I consent to Catalyst Miami releasing my name, phone number, email address, and the responses to the above questions to Beyond the Bars, which is a 501c3 nonprofit organization whose mission in South Florida is to build the social and economic power of workers with criminal records and their families. I consent to being contacted by Beyond the Bars about rights as workers with criminal records and to get involved.

Submitting your form

After you click Submit, you will receive an email with next steps. We will contact you as soon as possible. If you haven'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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*If you are also interested in assistance with tax preparation, please click here to request an appointment. ________________________________________
By submitting this intake form, you are OPT-IN and are consenting to receiving SMS text messages from Catalyst Miami for appointments, events and general outreach purposes at any time while inquiring about or receiving services. Message frequency may vary. You may reply STOP to opt-out of future messaging at any point. Reply HELP for more information. Message and data rates may apply.

We do not rent, lease, or sell customer lists or any data collected on our site to third parties. Catalyst Miami does not sell, share, or lease personal information with third parties for marketing/promotional purposes.

Click here to see our Privacy Policy.
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"By submitting this request for services, I attest that the information I am providing is true and correct."