Member Referral Form

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Member Information

Name (required)

Date of Referral (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

Phone (required)

Email (required)

Best way to contact (required)

Date of Birth (required)

Referral Source

Your Name (required)

Relationship

Agency name (if any)

Office Phone

Cell Phone

Email (required)

Best way to contact

In order to be considered for membership, all referrals are required to have a diagnosed mental illness as well as a copy of their diagnosis signed by a doctor, therapist or nurse practitioner. Hospital discharge summaries, medication evaluations, psychiatric evaluations or letters on letterhead signed by one of the previously mentioned personnel are acceptable.

GOC’s services are available to any Adult (over 18 years old), who is living with a mental health diagnosis. Our focus is on those adults with a severe and persistent illness but anyone with a diagnosed mental illness is welcome.

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

Thank you for completing this registration form and for your interest in GOC membership.
Referrals are kept on file for 90 days. GOC will be contacting referrals within 14 days of receipt.

You can mail or email this application to:
GAINESVILLE OPPORTUNITY CENTER
102 NE 10th Ave., Unit 2
Gainesville, FL 32601
Phone: (352) 224-5523 | Email: info@goclubhouse.org | Website: www.goclubhouse.org

You you prefer you can also download the form and bring it in or email it.

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