Application for ATI

What is your gender?

male

female

What is your age in years?

Which best describes your racial/ethnic identity?

What is your highest level of education?

Are you currently licensed as a therapist?

yes

no

Don't know how to answer

If you answered yes to the question above - which best describes your professional field?

How many years of experience do you have in your current field?

What is you annual income?

What is your marital status?

I hereby certify that all of the information provided in this application is complete and true to the best of my knowledge. I agree to submit a testimonial video regarding receiving a scholarship and I hereby grant permission to ATI to use my name, video and likeness in promotional materials in the event that I am selected to receive a scholarship award.

I Agree