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Admissions Intake Form (NEW)

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

  • RESIDENTIAL TREATMENT APPLICATION FOR TAMPA & OCALA

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Referral Source

  • Medical Screening

  • For example, limited activities or limited ability to get on a top bunk in your dorm room.

  • Insurance Information

  • Consent for Evaluation, Assessment, Treatment And Release of Referral Information

    Before we begin working with you, we are required to have your consent for evaluation, assessment and, if appropriate, treatment. Please download and upload a completed version of this consent with your intake form.

    Download Consent Forms →
  • Max. file size: 200 MB.

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?

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 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.

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.