Need Help? Call (813) 881-1000

Admissions Intake Form

Mission: We are passionate about healing individuals, families, and communities challenged by substance use disorders and related mental health conditions
  • INQUIRY INTAKE FORM

  • Date Format: MM slash DD slash YYYY
  • :
  • Caller Details

  • Date Format: MM slash DD slash YYYY
  • Client Details

  • Date Format: MM slash DD slash YYYY
  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Notes

  • Department of Corrections Only

  • If yes, a page titled legal history will be required to complete the application. (Score sheets are acceptable). ALL adult charges are required.
  • Medical Review

  • Substance Use

  • Date Format: MM slash DD slash YYYY
  • Mental Health History

  • Current Medications

  • Medical History-Current or History Of

  • CORONAVIRUS COVID-19 CLIENT SCREENING FORM

  • The following screening questions identify risk factors and is intended to alert staff to warning signs and symptoms related to the Coronavirus (COVID-19) for clients who present for treatment services. All clients wishing to enter treatment at Phoenix House Florida must test negative for COVID-19 via Nasopharyngeal PCR test.
  • Date Format: MM slash DD slash YYYY
  • Part 1: (Low Risk)

  • Part 2: (Medium/High Risk)

Need Help?

At Phoenix House Florida, we have a passion for healing. If you or your loved one are in need of subtance use treatment, we are here to help. Give us a call or submit our appointment request form today.

Contact Us Now

How Can We Help?

At Your House

There’s no one-size-fits-all approach to recovery. Outpatient treatment must follow a continuum of care that starts with a thorough needs assessment and ends with recovery monitoring.

The Derek Jeter Center

The Derek Jeter Center Adolescent program in Brandon, FL provides comprehensive outpatient services that help families deal with teen substance use and related mental health conditions.

At Our House

For some patients, stepping away from the buzz of everyday life is the only way to make a full recovery. Inpatient treatments help patients refocus their recovery efforts to achieve positive, long-lasting outcomes.