Orientation Questionnaire

If you haven't yet, please watch the below video that outlines the benefits and challenges of an MBSR class before enrolling in the course.

Now please complete the following form.

Please complete the following form and submit your tuition payment below to apply for a class registration. Dr. Erin will be in contact with you shortly after submission for a short phone interview and to let you know the next steps.


Thank you for filling out these forms. We realize the personal nature of these questions. Please be assured that the completed forms are kept in strict confidence. It is important for the teacher to know as much about you as possible to be able to best support you in your decision to take this class. 


If you have any questions, please call 518-560-1819


Orientation Questionnaire

Acknowledgement and Waiver of Liability &

Confidentiality Statement

I accept full responsibility for my health and voluntarily complete this Acknowledgement and Waiver of Liability. I understand and agree that the services and tools offered in the Mindfulness and Compassion programs offered by the teacher of the Mindfulness Center of the Capital Region, its officers, employees, contractors and agents are not intended to replace or be substituted for medical or psychiatric care. It is recognized that the trainings inherent in the programs may at times make participants feel vulnerable.


Mindfulness and Compassion programs are not therapeutic interventions for psycho-pathological disorders as defined in the DSM, and are not intended as such. By completing this release and consent, I assume all risk for any physical or mental or other consequences of participating in the program. By signing this release, I also specifically and expressly agree to hold harmless, indemnify and release the teacher of the Mindfulness Center of the Capital Region, it's officers, employees, contractors and agents from any and all liability for the results of the educational guidance that will be or have been provided.


Moreover, I acknowledge that the particulars shared in these classes by other participants are to be maintained as confidential. I will not blog or otherwise report on content shared in these classes in any form of media.


By checking the box below and entering my name in the signature box, I am agreeing that this is to be treated as if it were my signature, and that I am equally as bound to this waiver as if it were physically signed.

Tuition Remittance

We utilize tiered pricing for MBSR programs. Please pay what you can afford. Tuition is due at the time of registration. If the class is not for you, you can receive a full refund before the start of week two. If you would prefer to pay by check, please mail a check to Erin Walborn, 920 Stony Point Rd, Castleton, NY 12033.

$300

Scholarship Rate

$450

Regular Rate

$600

Contribution Rate

$150 will be donated to those in need of a scholarship.

Full

Scholarships

There are a limited number of full-tuition scholarships available for those in need. Please submit an application online by clicking below or by contacting your instructor directly.

Scholarship Application