LACT Enrollment Form

LACT Enrollment Form

P.O. Box 80235 Baton Rouge, Louisiana 70898-0235 | www.LASACT.org
Louisiana Addiction Counselor Training (LACT) Program Total Application Packet
GENERAL INFORMATION:

All information requested on the Application form is confidential.

All information requested is required for the successful completion of the application for admission to LACT. An e-mail address is required for all applicants to communicate with LACT.

Applications for all LACT courses are accepted on a first-come, first-served basis as space is available.

Fees are fully refundable upon written request until two weeks prior to the start of each course.

LACT will acknowledge receipt of applications by e-mail. Detailed information about classes will be provided by email prior to the start of the student’s first session. No book purchases are required.

For additional information, contact the LACT Director, Nya Skipper, at lact@lasact.org

All students must schedule an orientation Zoom meeting upon applying.

APPLICATION FEE:

The Application fee to become a member of LASACT and get a discounted tuition rate is $185. This amount includes LASACT dues through December 31 of the current year ($90) + materials fee ($95). Convenience fees will be applied as necessary.

Louisiana Addiction Counselor Training (LACT) Program students — membership MUST be kept current in order to continue to receive the discounted tuition rate. Failure to do so will result in loss of student member status. The LASACT membership renewal fee is $90 due in December of each year.

TUITION:

Students are required to pay the Application fee of $185, which includes LASACT Membership through the end of 2025. The Application Fee must be paid upon submitting enrollment forms.

Tuition payments must be paid in full per quarter (4 Quarters) before moving on to the next quarter.

Tuition payments can be made online here: https://www.lasact.org/category/lactschooltuitionpayment

TUITION PAYMENT PLANS:

12 Monthly Installments

LASACT Members | $ 100.00

Non-LASACT Members | $ 200.0

4 Quarterly (Every 3 months) Installments

LASACT Members | $ 300.00

Non-LASACT Members | $ 600.00

2 Semi-Annual Installments

LASACT Members | $ 600.00

Non-LASACT Members | $ 1,200.00
Applicant Information
COURSE OFFERINGS: Indicate your Enrollment Type*

All 4 Quarters - Full EnrollmentMakeup Quarter 1: PharmacologyMakeup Quarter 2: Counseling Theories & Skills, Part 1Makeup Quarter 3: Counseling Theories & Skills, Part 2Makeup Quarter 4: The Counseling Process
Tuition Payment Indication*

12 Monthly Installments of $100 / month4 Quarterly Installments of $300 / every 3 months2 Semi-Annual Installments of $600 / every 6 monthsFinancial Aid: Louisiana Rehabilitation ServicesFinancial Aid: Betty Breen Memorial Foundation
Name*

First NameLast Name/M.I.
Preferred Pronouns
Date of Birth*

MonthDayYear
Date
Email Address (Required)*
example@example.com
Work Phone Number*
Please enter a valid phone number.
Cell Phone Number (if applicable)
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Title
Employer
Race/Ethnicity*

WhiteBlack or African AmericanAsianAmerican Indian and Alaska NativeNative Hawaiian and Other Pacific IslanderOther
Primary Language Spoken*

EnglishSpanishFrenchGermanChineseVietnameseOther
Armed Forces/Veteran:*

YesNo
Gender*

MaleFemaleNon-Binary
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Education*

High SchoolAssociatesBachelorsMastersDoctorateOther
Credential Information

Type N/A in the first box if you do not have any of the credentials in either table below.

ADRA Credentials*

	Type LAC	CAC	RAC	CIT	LPP	CPP	RPP	PSIT	CCS	CCGC	ATA
No.
Exp. Date

LASACT Certificates/Other Credentials*

	Type AADC	CCJP	CCDP	CCDP-D	PRSS	LPC	LMFT	LCSW	LMSW	SAP	OTHER
No.
Exp. Date

LACT LETTER OF INTENT

Be sure to attach a Letter of Intent that outlines your interest in the LACT Program. Our goal after reading your letter is to have an understanding of your career goals and how we can help you to achieve said goals. The Letter of Intent should be in Times New Roman font, double-spaced, and no does not need to be longer than a single page. Although the letter is not formal, we ask for the formatting and vocabulary to be professional.
SUBMIT LETTER OF INTENT*

Cancelof
LRS Funding

Be sure to document the first and last name of your LRS Counselor as well as an email address below. You must already be assigned a counselor to denote LRS as your form of tuition payment, otherwise your application will be considered null and voided. Please reach out to LRS to confirm your eligibility prior to applying to the program.
LRS Counselor Name

Counselor First and Last NameCounselor Email
Betty Breen Funding

Be sure to upload a copy of your Betty Breen Approval Letter. You must already be approved for Betty Breen funding to denote Betty Breen as your form of tuition payment, otherwise your application will be considered null and voided. Please reach out to Betty Breen to confirm your eligibility prior to applying to the program. Betty Breen does not pay LACT Application Fees. Student is responsible for fulfilling the $185 Application fee upon applying.
SUBMIT BETTY BREEN APPROVAL LETTER

Cancelof
Payment Information

$5 - $10 credit card convenience fee will be applied to all LACT applications
My Products*
prevnext( X )
LACT Enrollment FeeEnrollment Fee of $185 which includes $90 LASACT dues for the current calendar year; $95 materials fee; $10 Credit card convenience fee.
$195.00



Reinstate Membership - Re-Enrolled StudentMembership has expired since time of previous enrollment. Price includes: $90 Annual Dues + $25 reinstatement fee + $5 transaction fee for all credit/debit card payments.
$120.00 Quantity



Renew Membership - Re-Enrolled StudentMembership is due for renewal from the time of previous enrollment. 2024 Membership must be renewed by March 31st, 2025. Price includes: $90 Annual Dues + $5 transaction fee for all credit/debit card payments.
$95.00 Quantity



No Fee - Re-Enrolled Student with Active 2025 Membership (LACT DIRECTOR PERMISSION ONLY!)
$ Free Quantity



Louisiana Rehabilitation Services (LRS) Financial AidLRS will be billed by LASACT for your Application Fee
$ Free Quantity



Betty Breen Financial AidBetty Breen does NOT pay LACT Application Fees. Student is responsible for the full amount as listed: Enrollment Fee of $185 which includes $90 LASACT dues for the current calendar year; $95 materials fee; $10 Credit card convenience fee.
$195.00



Total

$0.00
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LACT Enrollment Form

Louisiana Addiction Counselor Training (LACT) Program Total Application Packet

Applicant Information

Credential Information

LACT LETTER OF INTENT

LRS Funding

Betty Breen Funding

Payment Information