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     
“Success has nothing to do with what you gain in life or accomplish for yourself. 
It is what you do for others." 
-Danny Thomas
**Eligible for GRANT
FUNDING?
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
Copyright 2009 - 2018.   Village Counseling Center of Gainesville, Inc.
HomeReferralsProgramsServicesFormsTeamResourcesLocationsContact Us

Client Full Name

Birth Date

Age

Gender

Street Address

City & Zip Code

County

Best Phone Number

Former VCC Client

Services Court Ordered

School/Employer


If referred client is a child, please provide the following caretaker information

Parent/Caregiver

Relationship

Custody Status


Reason for Referral/Presenting Problem 




Services Requested




Treatment Location/s Preferred

Willing to Commute to Gainesville


Type of Funding

Eligible for Grant Funding (See right)

Funding Comments



Your Name

Primary Phone Number

Email Address

Referring Agency

VCC Recommended By


Additional Notes, Information, Questions or Requests