Obtaining CCS Program Application
This application is to be completed by RACs, CACs, or LACs only.
Please complete this application in full. Your responses will help us confirm eligibility and report outcomes to our funding partners.
SECTION 1: Applicant Information
Do you currently reside/work in East Baton Rouge Parish?
*
Yes
No
Name
*
Last Name
First Name/M.I.
Email Address (Required)
*
example@example.com
Confirm Email Address (Required)
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number (if applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
*
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Position Title (Optional)
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Non-Binary
Race/Ethnicity
*
White
Black or African American
Hispanic
Asian
American Indian and Alaska Native
Native Hawaiian and Other Pacific Islander
Other
Highest Level of Education Completed
*
High School Diploma or High School Equivalency
Associates
Bachelors
Masters
Doctorate
Professional Degree (e.g., JD, MD)
Vocational or Technical Training
Other
Marital Status
*
Single
Married
Legally Separated
Divorced
Widowed
Primary Language Spoken
*
English
Spanish
French
German
Chinese
Vietnamese
Other
Current Member of Armed Forces/Veteran:
*
Yes
No
SECTION 2: Counselor-In-Training Credentialing Information
Are you currently a RAC, CAC, OR LAC?
*
Yes
No
RAC/CAC/LAC Number
*
Date RAC/CAC/LAC Credential Issued
*
-
Month
-
Day
Year
Date
Date RAC/CAC/LAC Credential Expires
*
/
Month
/
Day
Year
Date
Have you ever tested for the CCS credential?
*
Yes
No
If so, please indicate how many times you have tested:
Yes
No
Additional Credential Information
Type N/A in the top-left box of the applicable table if you do not have any of the credentials listed below.
ADRA Credentials
*
Rows
Type LAC
CAC
RAC
CIT
LPP
CPP
RPP
PSIT
CCS
CCGC
ATA
No.
Exp. Date
LASACT Certificates/Other Credentials
*
Rows
Type AADC
CCJP
CCDP
CCDP-D
PRSS
LPC
LMFT
LCSW
LMSW
SAP
OTHER
No.
Exp. Date
Is there anything LASACT should know that may effect your program eligibility?
Submit
Disclaimer: LASACT does not discriminate on the basis of any responses provided on this form. All information is used solely to determine eligibility and program placement. Participation in the Recovery Ready Workforce Initiative is open to all qualified individuals regardless of race, color, national origin, sex, age, disability, religion, sexual orientation, gender identity, or any other protected characteristic.
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