Fall 2021 - Spring 2022

 Please complete the form as fully as possible to enable us to act on your application. If you have any questions, please contact certificate@meditationandpsychotherapy.org
Please note there is a $500 application fee that is credited to your tuition upon acceptance and refunded if not accepted. Please send your payment via PayPal using this link. If you have any questions about this and/or are not able to pay the fee through PayPal, please email certificate@meditationandpsychotherapy.org. 
Contact Information

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* 1. First Name

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* 2. Last Name

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* 3. Email

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* 4. Address

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* 5. City

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* 6. State

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* 7. Postal Code

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* 8. Country

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* 9. Date of Birth

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* 10. Work Phone

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* 11. Cell Phone

Professional Experience

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* 12. Education (institution, degrees granted, years of graduation)

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* 13. Licensed as:

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* 14. Year of licensure

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* 15. Current employment

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* 16. Past employment (you may upload a CV if necessary)

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* 17. Upload CV here if necessary

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 18. Areas of specialization/advanced training

Meditation/Mindfulness Experience

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* 19. Do you have experience with meditation?

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* 20. Do you have an active meditation practice at present?

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* 21. If so, how often do you practice?

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* 22. What style/in what tradition do you practice?

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* 23. When did you begin?

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* 24. Have you worked closely with any particular teachers?

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* 25. If so, who?

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* 26. Have you done any meditation retreats?

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* 27. If so, please give approximate dates and durations

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* 28. Please describe experience in other spiritual/religious traditions

Personal

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* 29. Are there any reasons (personal, psychological, medical) that would make participation difficult?

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* 30. If so, please describe:

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* 31. What brings you to this program, and what do you hope to gain from attending? (Please limit to 500 words)

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* 32. If you are applying at the scholarship rate, please describe the circumstances due to which you need financial assistance for this program.

Final Submission

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* 33. How did you find out about this program?

Please remember to send the $500 application fee (accredited upon acceptance and refunded if not accepted) via PayPal using this link. If you have any questions about this and/or are not able to pay the fee through PayPal, please email certificate@meditationandpsychotherapy.org. 

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* 34. By typing my name below, I am confirming that the information above is true, complete, and accurate

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* 35. Today's Date (MM/DD/YYYY)

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