Alternative Module Request: Intensives & Retreats
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.

To assess the equivalent of an intensive (e.g. MBCT Intensive Training & Retreat, MBSR Intensive Training & Retreat), the fee is $80.
NOTE: alternative module assessment fees are non-refundable, regardless of the outcome of your request.

Payment Options:
• Mail us a cheque made out to "The Centre for Mindfulness Studies"
• Drop by our office with a cash or cheque payment
• Make the payment on Ticketleap at https://centreformindfulnessstudies.ticketleap.com/alternative-module/

As a charity, we do not charge HST. However, payments made via TicketLeap are subject to a transaction fee.
Email address *
Your Full Name *
Your answer
Phone Number (###-###-####) *
Your answer
Module to be considered for replacement *
Description of alternative training/instruction *
Your answer
Date Completed (approximate date is fine) *
MM
/
DD
/
YYYY
Hours of Training *
Your answer
Location *
Your answer
Name of Facilitator or Supervisor *
Your answer
Submit
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