BMAC Client Inquiry Form

1
Your Contact Details* This field is required.Tell us more about yourself and how to get into contact with you
Your Name
Your Email Address
Your Phone Number
2
What is the primary service that you are seeking from BMAC at this time?* This field is required.Think of which is the most important service for right now?
Help paying for rent
Help paying utility bills
Homeless emergency and in need of a place to live
Options for permanent housing (elderly and persons with disabilities and/or chronically ill)
Food (Nutrition Assistance)
Pro Bono legal counsel
Home repair and/or weatherization for a home
BMAC's Employment & Job Training programs
BMAC's Financial Coaching & Asset Building programs
BMAC's Tutoring & Adult Literacy programs
I don't know? I'm not sure yet?
3
Are you a Veteran?* This field is required.Any Veteran who served in active military, naval, or air service.
Yes
No
4
Please tell us how BMAC can assist you. What are your needs?Please leave all your questions and comments in this area. You will have an opportunity to provide more specific details about yourself afterwards.
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Large
Normal
Small
Ok
Ok
5
Would you like to provide some additional information about yourself so that BMAC can inform you of any services and assistance you may be eligible for?All information is kept confidential and will only be shared with staff at BMAC who will be assisting you.
YESNO
6
BMAC Services Eligibility Guide

Please answer any or all of the following quetsions to tell us more about yourself and your situation. We'll connect you with our programs and services that best suit your needs.
7
What is your residential address (if applicable)?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
What county do you live in?
Walla Walla County
Columbia County
Garfield County
9
Do you live in any of the following neighborhoods in Walla Walla?
Blue Ridge
Edith and Carrie
Washington Park
None of the above
10
Which best describes your present living conditions?
I am homeless, I have nowhere to live
I am living in a shelter
Nursing Home, Assisted Living Facility, Adult Family Home, or Veteran's Home
I am temporarily living in someone else's home
I am renting a home/apartment/room
I own my home
11
How old are you?We ask because many eligibility requirements for social services are dependent on age.
12
How old are you (by range)?
12-17 years old
18-24 years old
25-64 years old
65 or older
13
How many people are in your household (including yourself)?
1 (just me)
2
3
4
5 or more
14
Do you live with any children under 18?
Yes
No
15
Which best describes your employment status?
Unemployed and currently unable to work
Unemployed and looking for work
Working part-time
Working full-time
Retired
16
What is your highest level of education you have received?
Some high school--did not graduate
High School Graduation or equivalent certificate
Some College, not finished
2-Year College degree program, Associate's Degree
4-Year College degree program, Bachelor's Degree or higher
17
What is your household's approximate monthly income?Enter an estimated dollar amount
18
Are you seeking legal advice regarding a civil matter? (e.g., divorce, custody, parenting plan, landlord/tenant issue, etc.)
Yes
No
19
Please describe any more details about your living situation and any specific needs you or your family may have for assistance.
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