- a 7 Approved For Release 2003/09/10 : CIA-RDP96-00788R _CPYRGHT | 1977002 100S5EIONFIDENTIAL Monroe Institute of Applied Sciences GATEWAY PROGRAM APPLICATION 1. NAME Address : Date of Birth _____ > City State Zip Sex Home Phone { ) Married __— Business Phone ( ) Children Present Occupation Person in closest association with you: Name & Address a Phone { } , EDUCATION High School —————_—__$_$_$__$_$—$_ Graduate Work ————________— College —____—— Other . PHYSICAL Height ————___-_________—__ Weight —— —_——————————— Any chronic illness, abnormalities, disabilities __._~=—» Snr Major illnesses, surgical operations or accidents I Presently on medication Special diet Recent physical.exam For what reason Do you participate in $ Sat type Exercise daily General health _ Are you right or left handed ——______— . MENTAL Have you undergone psycho-therapy /analysis . How long ————— __ Name and address of therapist aU cae Ever hospitalized for mental breakdown or iliness  —_—_—_—_————————§ ———— sees Details Do you have any special dislikes Answer by number (1) Very Strong (2) Average (3) No Fear Insects : Animals ———_____—_ Snakes Crowds Heights Closeness —_—____. Darkness __..__ Other Events/things that please you most nee 5. Participation in any other mind training activities: TM, Silva, ete. —— — — $$ @—- Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
~~ Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1 wo re CPYRGHT Present use of entertainment or psychotropic drugs such as alcohol, barbiturates, amphetamines, etc. Drugs: See How often SSS What areas of personal development do you feel you need most? eee Eee How did you learn of Monroe Institute? GATEWAY PROGRAM SESSIONS Session Fee | Deposit Deposit refundable until EXCURSION $ 55 $ 15 Two weeks before the session WEFKEND — DISCOVERY 350.. 75. Four weeks before the session EIGRRyY EXPLORATIONS 950, . 200. Six weeks before the session (Fee varies with location) ’ | desire to participate in the following type of session _ . It is scheduled to be held at __THER CENTER == son Daattle . The cost to me will be $ ____—=—S— saa indicated above. | enclose a Reservation Depositof $C, as indicated above. The balance of my Registration Fee will be paid: by me on the first day of my attendance. | understand and agree that my participation in the Gateway Program is solely for my own personal use and benefit, and that any information, experience, methods, techniques, or other data related thereto is for my own private use only. | therefore agree that | will not release directly or indirectly any of the above through any public medium without the written approval by the Monroe Institute of Applied Sciences of the content of such public release. Please charge my OMaster Charge a VISA. Card No. exp. date Signed ow Date Send to: MONROE INSTITUTE OF APPLIED SCIENCES P. O. BOX 94C FABER, VIRGINIA 22938 (804) 361-1252 Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
PROFILE OF ADAPTATTOR TO" FigER"° 2003/09/10 : Cl INSTRUCTIONS: ( ) Subj. # 1. Before answering the questions below, please read the information Provided to you about the purpose of this questionnaire, protection of your right to privacy, etc. Try to answer each question below to the best of your ability. Do not spend too much time on any one question. Your first impulse is generally your best answer. PLEASE COMPLETE THE FOLLOWING BACKGROUND INFORMATION: Your Name: Fo (Please Print) Day Year A. SEX (Check one) C. EDUCATION (Check one) (1) Male (1) Less than high school (2) Female (2) High school graduate (3) Some college MARITAL STATUS (Check one) College graduate (1) Currently married (2) Separated, divorced, D. AGE or widowed (3) Never married Please mark one answer for each question beLow. Mark your answer Like this: (W] on [X | Answer Choices 3 Some- times Often DURING THE PAST MONTH, HAVE YoU... (Please answer each question below) Never Rarely Worried about something? Feit gloomy, blue? Been on edge, tense? Felt uneasy, troubled? Been unhappy? COPYRIGHT 1978 by IPEV Int'}. ., . . Reproduction by any process without permission violates copyright Laws. ITUTE FOR PROGRAM EVALUATION (IPEV Int*1) Bon 4654, Roanoke. Va. 24015 ( proved For Release 2003/09/10 CPYRGHT 700210038-1 DURING THE PAST MONTH, I'VE... (PLease answer each statement below) 6. Enjoyed talking with others. 7. Felt trusting of people. 8. Found work useful and interes ting. 9. Been involved, interested in things. 10. Felt needed and useful. ARE YOU LIVING WITH A SPOUSE, PARENT, OR SOMEONE IN A CLOSE RELATIONSHIP? (1) No (If you marked "no", skip the next 5 questions) (2) Yes (If you marked "yes", please answer the 5 questions below) Answer Choices . ] 3 4 Some- Almost times Often Always DURING THE PAST MONTH, HAVE You AND THIS PERSON (spouse, parent, etc.) .. » Been able to talk it through when | angry? - Spent enjoyable times together? [ | ARE THERE CHILDREN WHERE YOu LIVE? Mark one} QI No (If you marked "No", skip to Question 21 on reverse side) (2) “Yes (If you marked "Yes", please answer the next 5 questions} Rarely . Discussed important matters? - Felt close to each other? - Agreed about social activities and friends? Answer Chol ces 2 3 DURING THE PAST MONTH, HAVE YOU AND THE CHILD(REN)... . 16. Spent time talking with each other? 17. Spent time doing things together? 18. Treated each other with respect? 19. Felt close to each other? 20. Done things for each other? : CIA-RDP96-00788R001700210038-1 Please continus, an aeuense sida
CPYRGHT Approv r 5 Ay YOU INDICATE WHETHER OR NOT YOU HAVE pproved POprReleas#2003/09/10 CHRD ESB ONS aT ITE Te Toba cas OF ADJUSTMENT OR ACTIVITY DURING DURING THE PAST MONTH, HAVE YOU... 9 Some= THE PAST MONTH. PLEASE BE SURE TO ANSWER EACH QUESTION BELOW. arely times ; DURING THE PAST MONTH, HAVE YOU HAD PROBLEMS . | | | il 35. With Feeling Bad. (worried, unhappy, tense, etc. )? Usually Always 21. Had enough money to handle unexpected expenses? 22. Had enough money to pay your bills? . Been free from worry about debts? Answer Choices 1 2 3 DURING THE LAST MONTH, HAVE YOU , . Not -2 Times |-2 Times Once per MONTH per WEEK 24. Had headaches? 25. Felt hot, feverish? 26. Had spells of dizziness? 27. Waken from sleep feeling tired? 28. Had nausea (sick to stomach)? 29. Taken medication for headache? 30. Taken medication for stomach? Answer Choices 1 2 lo 1-2 Times DURING THE LAST MONTH... . Once per MONTH per WEEK 31. Have you used alcohol or non- prescription drugs? 32.. Have you gotten high on alcohol or drugs? 33. Has alcohol or drugs caused pro- blems between you & family members? 34. Has alcohol or drugs caused pro- blems in your thinking clearly? 4 most Daily (Mark one answer) QM) No problem (2) Some problem (3) Serious problem Enjoying Other People or your Daily Life? (Mark one answer) (1) No problem (2) Some problem (3)__ Serious problem In the Relationship with the Person Close to You? (Mark one answer) (0) ss I'm not in a close relationship (1) No problem (2)_____ Some problem (3)____ Serious problem In Relating to Children in the Home? (0) No children where I live (1 (2 (3 )___ No problem ) Some problem )—__ Serious problem With Having Enough Money to Handle Expenses? 1) No problem (2) Some: problem (3) Serious problem With Feeling Sick, or Problems with Health? (1) No problem (2) Sone problem (3) Serious problem In Using Too Much Alcohol or Drugs? (Mark one answer) (1) No problem (2) Some problem (3) Serious problem Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
Kpproved elease 2003/09/70 : BACKGROUND INFOR CPYRGHT From tome to time, people become involved 4n experiences that may change their Lives AN certain ways. ADAPTATION TO LIFE (PAL) grams over time. participate 44 that 4s your choice, PLease complete this background information first. Your participation in this evaluation of our program PAL Scake items themselves. 45 very much appreciated. BACKGROUND INFORMATION: Name Street City & State YOUR MARITAL STATUS (Check one) (1 Currently married ) (2) Separated, divorced, widowed (3) Never married SEX (Check one) (1) Male (2) AGE EDUCATION (Check one) Q Less than high school (2 High school graduate HEIGHT: | feet inches pounds DO YOU SMOKE CIGARETTES? (Check one) (1) Not at all (2) About 1/2 pack per day WEIGHT: HOW MUCH COFFEE DO YOU DRINK EACH DAY? None or rare cup About 1-2 cups per day DO YOU WATCH TV? (Check one) (1) None or rarely (2) Less than 1 hour per day (3) 1-2 hours per day AVERAGE HOURS OF SLEEP PER NIGHT (1) _ 4-5 hours (2) «5-6 hours (3) 6-7 hours OCCUPATION OR PROFESSION: Approved For Release 2003/09/10 et The attached scale provides information on youA PROFILE OF , and will be used only to measure the effects of our pro- The information you provide will nemain strictly confidential and the nesults will be reported in group averages. ° You, of course, ane free not to Then go on and complete the Today's Date Phone cipe (3) Some college (4) College graduate (Type of degree (3) About 1 pack per day (4) Over 1 pack per day (Check one) (3) 3-4 cups per day (4) 5 or more cups per day (4) - 3-4 hours per day . (5) 5 or more hours per day (Check one) (4) 7-8 hours (5) 8 or more hours : CIA-RDP96-00788R00T7G0Z10038-1 Prog.