Alternative Treatment International, Inc.
About Us
Psychotherapy Treatments
Staff
A.T.I. Relapse Prevention & Recovery Tools
Relapse Perception & Prevention
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Admission Form
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New Admission Form

To begin the admission process and immediate therapeutic care, please complete the Admission Form below and click the "Submit Form" button when completed. Completion of all fields marked with an is required for application submission. Upon receipt of your Admission Form, our Admissions Department will contact you personally by telephone to answer any questions that you may have.

Please Note The Following:

Our staff will meet you at the airport and transport you to the facility.

You will be flying into Tampa International Airport or St. Petersburg-Clearwater International Airport, met by a member of our staff and transported directly to the facility.

* Last Name
* First Name
* Age
* Sex Male  Female
* Email Address
* Phone Number
* Street Address
* City or Town
* State or Province
* Postal or Zip Code
* Country
* Requested Admittance Date
Types of Substances Used Drugs   Alcohol   Inhalants
Other Substances Used
* Do you need Detoxification? Yes  No
Do you suffer from Depression? Yes  No
Other Mental Disorders (Please List)
* Any and All Medications Currently Prescribed
* Any and All Medications Actually Being Taken Presently (including over-the-counter medications)
* Projected Length of Stay
* Method of Payment
* What Search Engine did you use to find us?
* What key words did you type in to find us?
Additional Comments or Questions
Fields marked by an * asterisk are required.
Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, or if you are not using a forms-capable browser, you may email your response to this form to: info@alternative2rehab.com