VILLAGE COUNSELING CENTER
Online Referral
INTER-AGENCY REFERRALS ONLY:
Feel free to call us or submit this form to make a referral. If using this referral form, you will receive an immediate confirmation notice that your referral was submitted. Within one business day, you will then receive an email verifying that we have received your referral and that contact is being made to schedule an appointment with the client. Thank you very much for your referral and please call our office directly at (352) 373-8189 if you need any assistance.
NOTE: This form is NOT for self referrals. If you are personally interested in receiving services at VCC, please call our office at (352) 373-8189. Also, we do not accept Medicaid or Magellan referrals (other than CBHA referrals) at this time. Thank you.
Service/s Requested:
Funding Source?
Services Court Ordered?
Referred By:
Client Full Name:
Date of Birth:
Age:
Residing Address:
City/County:
Primary Phone:
Parent/Caretaker:
Relationship:
If referred client is a child, please provide caregiver information:
Presenting Problem/Reason for Referral: (Please be specific)
Other/Comments:
Other/Comments:
Primary Phone:
Email Address:
Agency:
Additional Notes/Requests:
“Success has nothing to do with what you gain in life or accomplish for yourself.
It is what you do for others."
Danny Thomas
Own Transportation?
Treatment Location Preferred?
Authorization No.:
