Request Help - Love INC Columbia Basin

Client Request Form

Thank you for reaching out to Love INC Columbia Basin! Please fill out the form below so we can better understand how to help you. Your information is kept confidential. If you need assistance completing this form, please call us at 509-764-8276.

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Date of Birth

Contact Number(Required)

Email(Required)

Street Address(Required)

Do you require a Spanish speaking volunteer to contact you?

Yes

How did you learn about Love In the Name of Christ?

Family or Friend

Church

Organization or Agency

Online

Other

How many in your household? (Please include adults and children, their ages and other information you think can be useful).(Required)

Have you been helped by Love In the Name of Christ before?(Required)

If so, when?

What is your request for assistance or help?(Required)

How can Love In the Name of Christ pray for you?(Required)

Attachments

Include any screenshots, logs, or documents that may help our support team resolve your request faster.

Max. file size: 64 MB.

Client Request Form

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