Feel free to call us or complete this form to make a confidential referral.  After submitting this form, you will receive an immediate confirmation that your referral was submitted.   We will then establish contact with you and/or directly with the client to discuss our services, fees and possibly schedule and an intake appointment.  We apologize but we do NOT accept Private Insurance, Medicare, Medicaid or other Medicaid payment.

Grant funded Trauma Services may be available at no charge for children who have been exposed to trauma, who reside in Alachua County and who have no funds to pay for services.  See below for eligibility requirements.** 

Thank you very much for your referral and please call our office at (352) 373-8189 if you need any assistance. You can also email us at info@villagecounselingcenter.net     
Primary Service/s Needed
Type of Funding
Services Court Ordered
Your Name
Client Full Name
Birthdate
Age
Street Address
City & ZIP Code
Best Phone No
Parent/Caregiver
Relationship
If referred client is a child, please provide caretaker information:
Presenting Problem or Trauma, Reason for Referral: (Please be specific)
Funding Issues
Primary Phone No
Email Address
Agency
Additional Notes, Information, Questions or Requests
Former VCC Client
Treatment Location Preferred
Gender
County
Meet Grant Requirements?**
Current School/Employer
VCC Recommended By
“Success has nothing to do with what you gain in life or accomplish for yourself. 
It is what you do for others." 
-Danny Thomas
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**Eligible for GRANT
FUNDING?
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If the child referred meets the following conditions he/she may be eligible for trauma services at no charge:

- 3-11 years old
- Resides in Alachua County
- Exposed to trauma
- In need of treatment services
- IQ above 70
- Unable to access and/or 
  pay for trauma services
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Required Field
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Copyrighted, 2009 - 2017.   Village Counseling Center of Gainesville, Inc.
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