GAMBLING Training Course Enrollment

1
GENERAL INFORMATION

We are pleased to have you and look forward to supporting your professional development. Our program is designed to be self-paced, accessible, and fully online through our Moodle Learning Management System. Upon enrollment, you will have immediate access to all course materials and may begin working at your own pace.

Upon submitting your application, you will follow the steps sent via email and listed below in this document to be automatically enrolled and begin creating your Moodle account.
2
FINANCIAL AID ACCEPTED

Office of Behavioral Health
3
Tuition Payment Indication* This field is required.Please indicate your tuition payment plan.
Out-of-Pocket (Payment Plans Available)
Office of Behavioral Health
4
Name* This field is required.
First Name
Last Name
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Email* This field is required.
example@example.com
7
Phone Number* This field is required.
Area Code
Phone Number
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Employer Name* This field is required.
10
Position Title* This field is required.
11
Employer Phone Number* This field is required.
Area Code
Phone Number
12
Race/Ethnicity* This field is required.
White
Black or African American
Asian
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
13
Primary Language Spoken* This field is required.
English
Spanish
French
German
Chinese
Vietnamese
Other
14
Armed Forces/Veteran* This field is required.
YESNO
15
Gender* This field is required.
Male
Female
Non-binary
16
Marital Status* This field is required.
Single
Married
Separated
Divorced
Widowed
17
Highest Form of Education* This field is required.
High School Diploma/GED
Associates
Bachelors
Masters
Doctorate
Other
18
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
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
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
19
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
1 of 2
20
LRS CounselorIf using LRS, you must already be approved for funding before enrolling.
Counselor First and Last Name
Counselor Email
Counselor Phone Number
Authorization Number
21
VA CounselorIf using VA Chapter 31, you must already be approved for funding before enrolling.
Counselor First and Last Name
Counselor Email
Counselor Phone Number
Authorization Number
22
Checkout* This field is required.LASACT currently accepts ACH, credit/debit card payments, and 3rd Party Financing Providers (Klarna and AfterPay)
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Office of Behavioral Health
Includes:
LASACT Membership through December 2026 ($90)
Application Fee ($95)
2.9% Transaction Fee
Edit
Back
LASACT Current Member | Out-of-Pocket
Includes:
GAMBLING Tuition ($450)
Application Fee ($95)
2.9% Transaction Fee
Edit
Back
LASACT New Member | Out-of-Pocket
Includes:
LASACT Membership through December 2026 ($90)
GAMBLING Tuition ($450)
Application Fee ($95)
2.9% Transaction Fee
Edit
Back
Non-Member | Out-of-Pocket
Includes:
GAMBLING Tuition ($600)
Application Fee ($95)
2.9% Transaction Fee
Edit
Back
Total cost
Should be Empty: