AEP #2 Training Course Enrollment

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Training Courses Available* This field is required.Please select the course you are enrolling in to
Gambling Disorder Treatment Training ONLY
Clinical Supervision Training
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Tuition Payment Indication* This field is required.Please indicate below your tuition payment plan. LRS and Betty Breen users will require additional information upon submission at the end of this form.
Out-of-Pocket (Payment Plans Available)
Office of Behavioral Health
Louisiana Rehabilitation Services
Betty Breen Memorial Foundation
Veterans Rehabilitation Services
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Full Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
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Email Address* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Address* This field is required.
Street Address
Street Address Line 2
City
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Please Select
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Afghanistan
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Other
Country
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Employer Name* This field is required.
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Position Title* This field is required.
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Employer Phone Number
Area Code
Phone Number
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Race/Ethnicity* This field is required.
White
Black or African American
Asian
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Other
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Primary Language Spoken* This field is required.
English
Spanish
French
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Other
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Armed Forces/Veteran* This field is required.
YESNO
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Gender* This field is required.
Male
Female
Non-Binary
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Marital Status* This field is required.
Single
Married
Separated
Divorced
Widowed
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Education* This field is required.
High School Diploma/GED
Associates
Bachelors
Masters
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Other
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Credential Information | ADRA Credentials* This field is required.Type N/A in the first box if you do not have any of the credentials in either table below.
LAC
CAC
RAC
CIT
LPP
CPP
RPP
PSIT
CCS
CCGC
ATA
No.
Row 0, Column 0
Row 0, Column 1
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Row 0, Column 10
Exp. Date
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Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Row 1, Column 8
Row 1, Column 9
Row 1, Column 10
No.
Exp. Date
LAC
Row 0, Column 0
CAC
Row 0, Column 1
RAC
Row 0, Column 2
CIT
Row 0, Column 3
LPP
Row 0, Column 4
CPP
Row 0, Column 5
RPP
Row 0, Column 6
PSIT
Row 0, Column 7
CCS
Row 0, Column 8
CCGC
Row 0, Column 9
ATA
Row 0, Column 10
LAC
Row 1, Column 0
CAC
Row 1, Column 1
RAC
Row 1, Column 2
CIT
Row 1, Column 3
LPP
Row 1, Column 4
CPP
Row 1, Column 5
RPP
Row 1, Column 6
PSIT
Row 1, Column 7
CCS
Row 1, Column 8
CCGC
Row 1, Column 9
ATA
Row 1, Column 10
1 of 2
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Credential Information | LASACT Certificates/Other Credentials* This field is required.Type N/A in the first box if you do not have any of the credentials in either table below.
AADC
CCJP
CCDP
CCDP-D
PRSS
LPC
LMFT
LCSW
LMSW
SAP
OTHER
No.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Exp. Date
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Row 1, Column 8
Row 1, Column 9
Row 1, Column 10
No.
Exp. Date
AADC
Row 0, Column 0
CCJP
Row 0, Column 1
CCDP
Row 0, Column 2
CCDP-D
Row 0, Column 3
PRSS
Row 0, Column 4
LPC
Row 0, Column 5
LMFT
Row 0, Column 6
LCSW
Row 0, Column 7
LMSW
Row 0, Column 8
SAP
Row 0, Column 9
OTHER
Row 0, Column 10
AADC
Row 1, Column 0
CCJP
Row 1, Column 1
CCDP
Row 1, Column 2
CCDP-D
Row 1, Column 3
PRSS
Row 1, Column 4
LPC
Row 1, Column 5
LMFT
Row 1, Column 6
LCSW
Row 1, Column 7
LMSW
Row 1, Column 8
SAP
Row 1, Column 9
OTHER
Row 1, Column 10
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LRS Counselor (SKIP if not applicable)LRS will pay for the following: Substance Abuse + Gambling, Gambling ONLY, Substance Abuse ONLY, Clinical Supervision, Application Fee, Membership Fee
Counselor First and Last Name
Counselor Email
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Betty Breen Approval Letter (SKIP if not applicable)
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Select Your Course Enrollment* This field is required.Below is a list of financial aid assistance programs that we accept here at LASACT. Prior to applying, please review these financial aid assistance programs to see if you qualify. We do not disburse refunds to applicants who seek financial aid assistance after out-of-pocket payments have been made. If you do not qualify for any of the following financial aid assistance programs, you must pay out-of-pocket in full upon submitting your application. LASACT does not accept any federal funding and cannot make arrangements for payments on behalf of applicants. If you believe that you may have a source of funding not already listed below, it is your responsibility to make those payment arrangements that comply with the system that LASACT already has in place. Please indicate your payment option below in the drop-down option. Once you have selected your payment option, your total will refresh to reflect your true total at checkout. LASACT currently accepts ACH, credit/debit card payments, and 3rd Party Financing Providers (Klarna and AfterPay)
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ORDER SUMMARY
Total costUSD
Gambling Disorder Treatment Training ONLY | 90 DAY COURSE
30-Hour Gambling Disorder Treatment Training

Please indicate your payment option below in the drop-down option. Once you have selected your payment option, your total will refresh to reflect your true total at checkout.
$FreeEdit
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OBH
OBH
LRS
VA
MEMBER | Out-of-Pocket
NON-MEMBER | Out-of-Pocket
Tuition Payment Indication
Clinical Supervision | 90 DAY COURSE
30-Hour Certified Clinical Supervision Training Course

Please indicate your payment option below in the drop-down option. Once you have selected your payment option, your total will refresh to reflect your true total at checkout.
$FreeEdit
Back
LRS
LRS
VA
MEMBER | Of-of-Pocket
NON-MEMBER | Out-of-Pocket
Tuition Payment Indication
Total cost $0.00
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