Alternative Module Request: 1-Day Course
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 a one-day course (e.g. CBT Primer, Mindfulness Core Concepts), the fee is $50.
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

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) *
Hours of Training *
Your answer
Location *
Your answer
Name of Facilitator or Supervisor *
Your answer
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