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 asterisk 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	Select one: Check Cash Visa/Mastercard American Express Discover
* What Search Engine did you use to find us?	Select one: Google MSN Yahoo Other
* What key words did you type in to find us?
Additional Comments or Questions
	* I have read and agree to the terms of A.T.I.'s Financial Policies located on the Program Fees portion of the website.
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@atiwellness.com