JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
BAFS Application
Application for Services & Housing
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First and Last Name
*
Your answer
Current Address
Your answer
Phone
*
Your answer
Email Address
*
Your answer
Do you have a substance use disorder that you are seeking services for?
Yes
No
Clear selection
Referred by:
Choose
Coos Health & Wellness
Community Corrections
Bay Area Hospital
DHS Child Welfare
Other
Race
African American/Black
Asian
Native American
Caucasian/White
Hawaiian/Other Pacific Islander
Choose not to answer
Other:
Clear selection
Ethnicity
Hispanic/Latino
Non-hispanic/Non-Latino
Choose not to answer
Clear selection
Primary language
Your answer
Gender
Male
Female
Nonbinary
Pronouns
Your answer
Disabled
Yes
No
Clear selection
Veteran
Yes
No
Clear selection
All services including housing are provided based on need and availability.
Services Requested (check all that apply)
Peer Mentoring
Treatment Services
Emergency Housing
Alcohol/Drug Free Housing
Health Care
Transportation
Employment
What Agencies Are You Working With?
Your answer
You can reach us at 541-756-3111 option 2
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of BAFS.
Report Abuse
Forms
