Alternative Module Request Form
You may request that an alternative course or work experience be considered as a replacement for required training as part of the MBCT or MBSR Facilitation Certificate Program by completing this form and submitting payment.

Assessment Fees:
• 1-day facilitation certificate module (e.g. Mindfulness Core Concepts, CBT Primer) $50
• 2-day facilitation certificate module (e.g. MBCT Basics, Inquiry Essentials) $70
• Intensives, Retreats, and Practicums $80

Please Note: we do not charge HST as we are a charity. Alternative module assessment fees are non-refundable, regardless of the outcome of your request.

Form & Payment Submission Options:
• Mail us your completed request form(s) and a cheque for the required assessment fee(s).
• Drop by our office with your completed request form(s) and the cash or cheque payment.

Email address
Your Full Name
Your answer
Todays Date
MM
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DD
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YYYY
Phone Number
Your answer
Full Mailing Address
Your answer
Facilitation Certificate Module to be considered for replacement
Your answer
Description of alternative training/instruction
Your answer
Date Completed
MM
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DD
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YYYY
Hours of Training
Your answer
Location
Your answer
Facilitator or Supervisor Name
Your answer
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