CPYRGHT
Approved For Release 2003/09/10
: CIA-RDP96-00788R001 70021 0038^^^p|Q
| ^|_
f
Monroe Institute of Applied Sciences
GATEWAY PROGRAM APPLICATION
1. NAME
.
Address
Home Phone
(
)
—
Business Phone j
)
Present Occupation_
—
Person in closest association with you: Name & Address
2. EDUCATION
High School
—
College
i
—
3. PHYSICAL
Height
Any chronic illness, abnormalities, disabilities _
Major illnesses, surgical operations or accidents
Presently on medication
^
Recent physical, exam
•
Do you participate inspects
—
Exercise daily
Are you right or left handed
4. MENTAL
Have you undergone psycho-therapy/analysis _
Name and address of therapist
—
How long
Graduate Work
Weight
Special diet
For what reason
What type
General health
Ever hospitalized for mental breakdown or illness
-
Details
——
Do you have any special dislikes
Answer by number (1) Very Strong
(2) Average
(3) No Fear
Insects
.
Animals _
Closeness
,
Snakes
Darkness
Crowds
Heights
—
uoseness
Events/things that please you most
'
Participation in any other mind training activities: TM, Silva, etc.
Approved For Release 2003/09/10
: CIA-RDP96-00788R001 70021 0038-1
S'
Approved For Release 2003/09/10
: CIA-RDP96-00788R001 70021 0038-1
CPYRGHT
Present use of entertainment or psychotropic drugs such as alcohol, barbiturates, amphetamines, etc.
Drugs:
How often
——
What areas of personal development do you feel you need most?
How did you learn of Monroe Institute?
GATEWAY PROGRAM SESSIONS
Session
Fee
Deposit
Deposit refundable until
EXCURSION
$ 55
$
Two weeks before the session
WEFKEND - DISCOVERY
/—i tvi-h
350.
.
75.
Four weeks before the session
DAY EXPLORATIONS
(Fee varies with location)
850.
200.
Six weeks before the session
I desire to participate in the following type of session
It is scheduled to be held at
THE CENTER
0n Date
The cost to me will be $
as indicated above.
I enclose a Reservation Deposit of $
as indicated above-
The balance of my Registration Fee will be paid by me on the first day of my attendance.
I 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.
I therefore agree that
I
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
Master Charge
VISA. Card No.
exp. date
Signed
.
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-RDP96-00788R001 70021 0038-1
CPYRGHT
PROFILE OF ADAPtWTf^d
f(5
r
fiflf
ase 2003/09/10
1700210038-1
INSTRUCTIONS:
(
\
ids
»
,
Subj
T
-
#
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.
2.
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:
(Please Print)
Today's
Date:
Month
Day
Year
A.
SEX
(Check one)
(1)
Male
(2)
Female
B.
MARITAL STATUS
(Check one)
(1)
Currently married
(2)
Separated, divorced,
or widowed
(3)
Never marri ed
EDUCATION
(Check one)
(1)
Less
than high school
(2)
High school
graduate
(3)
Some college
(4)
College graduate
Plea&e. maxk owe amweji
fan. each qae&tion below.
Mank
yoivi an&wea tike thl&
:
on.
| X
I
[Plea&e an&wen
exick qae&tion below )
Never
Rarely
1.
Worried about something?
2.
Felt gloomy,
blue?
]
3.
Been on edge,
tense?
4.
Felt uneasy,
troubled?
5.
Been unhappy?
Answer Choices
4_
Scme-
y
times
Often
DURING THE PAST MONTH,
I'VE
.
.
.
( Pleat e an&wen. each statement below)
Answer
Some-
times
rcea&e an&wen each statement below)
Rarely
times
6.
Enjoyed talking with others.
f
[
|
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7.
Felt trusting of people.
B.
Found work useful
and interesting.
'
9.
Been
involved,
interested
in things.
10.
Felt needed
and
useful.
|
]
VI bCM
HI
t
ARE
YOU LIVING WITH A SPOUSE,
PARENT, OR SOMEONE
I N A CLOSE RELATIONSHIP?
Jo
If you marked
"no",
skip the next
5 questions)
,1UnMUP -
[2)
Yes
( If y00 marked
"yes",
please answer the
5 questions
below)
DURING THE PAST MONTH.
HAVE YOU AND
11.
Been able
to talk
it through when
angry?
12.
Spent enjoyable times together?
13.
Discussed important matters?
14.
Felt close to each other?
15.
Agreed about social
activities
and friends?
Answer
cr
oices
Some-
times
Often
Almost
Always
—
ARE THERE CHILDREN WHERE
YOU LIVE?
(Mark
one]
—
N°
(JJ you marked "No", skip to Question
on reverse side)
Yes
( If y°u marked
"Yes",
please answer the next
5 questions)
Answer Choices
~|
jS™f
P>Sr
H,,E TO
'J
THE U
5SP
life
^ LPtREN )
•
•
•
•
Rarely
times
Often
Always
16.
Spent time talking with
each other?
[
j
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COPYRIGHT 1978 by IPEV Int‘1.
Reproduction by any pnoce&i without penmi&ilon violate* copynight law*.
INSTITUTE FOR PROGRAM EVALUATION (IPEV Infl)
Box 4654, Roanoke,
Va.
24015
Approved For Release 2003/09/10
17.
Spent time doing things together?
18.
Treated each other with respect?
I
“i
-
S
—
19.
Felt close to each other?
20.
Done things for each other?
CIA-RDP96-00788R001 70021 0038-1
Plea&e. wnti/mt, nn neuen&a
tiHa
CPYRGHT
DURING THE PAST MONTH,
HAVE YOU
21.
Had enough money
to handle
unexpected expenses?
L_
L___
22.
Had enough money to pay your bills? L___
_____
23.
Been free from worry about debts?
Approved F^3^Rel®li^003/09/410
___
Rarely
times
Usually
Always
;?
_____
DURING THE LAST MONTH.
HAVE YOU
.
.
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?
DURING THE LAST MONTH ....
31. Have you used alcohol
or non-
T
\
j
J
prescription drugs?
I
|
32.
Have you gotten high on alcohol
I
I
I
or drugs?
|
33.
Has alcohol
or drugs caused pro-
[
f”
j
blems between you & family members?
|
I
|
|
32.
Have you gotten high on alcohol
or drugs?
Answer Choices
2 Times
1-2 Times
Almost
Once
per MONTH
per WEEK
'J
Answer Choices
4__
Not
1-2 Times
1-2 Times
Almost
Once
per MONTH
per WEEK
Daily
YOU INDICATE WHETHER OR NOT YOU HAVE
CIOl^D$ED03m8ramM^^
OF ADJUSTMENT OR ACTIVITY DURING
THE PAST MONTH .
PLEASE BE SURE TO ANSWER EACH QUESTION BELOW.
DURING THE PAST MONTH,
HAVE YOU HAD PROBLEMS
.
.
.
35.
With Feeling Bad
(worried,
unhappy,
tense,
etc.)?
(Mark one answer)
(1
)
No problem
(2)
Some problem
(3)
Serious problem
36.
Enjoying Other People or your Daily Life?
(Mark one answer)
(1)
No problem
(2)
_
Some problem
(3)
Serious
problem
37.
In
the Relationship with the Person Close to You?
(Mark one answer)
(0)
I’m not in
a close relationship
(1)
No problem
(2)
Some problem
(3)
Serious problem
38.
In
Relating
to Children
in
the Home?
(0)
No children where
I
live
( 1
)
No probl em
(2)
Some problem
(3)
Serious problem
39.
With Having Enough Money
to Handle Expenses?
(1)
No problem
(2)
Some problem
(3)
Serious problem
40.
With Feeling Sick,
or Problems with Health?
(1 j
No problem
(2)
Some problem
(3)
Serious problem
41.
In Using Too Much Alcohol
or Drugs?
(Mark one answer)
(1)
No problem
(2)
Some problem
(3)
Serious
problem
34.
Has alcohol
or drugs caused pro-
I
I
I
I
I
blems
in your thinking clearly?
[__
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Approved For Release 2003/09/10
: CIA-RDP96-00788R001 70021 0038-1
CPYRGHT
pprovea i-or Keiease zuiw/uy/iu
: CIA-KL)Py6-0U7SoKUU1 /UU21UU38-1
BACKGROUND
INFORMATION TO PAL SCALE
F'lom tone
to
time,
people become Involved In experience* that may change their
WAPTATir
,
<
T/lC
a^
clie-d t>cale provide*
information on your PROFILE OF
nf,n
x
^
LIFE
PAL)
,
and mill, be abed only to measure the
effect*
of oar pro-
gram
over tone
The information you provide mill remain strictly confidential and
the re* alt* mUl be reported in group average*.
Vou,
of coune,
are
free, not to
participate if that a
your choice.
va
i
complete thi* background information
fir*t.
Then go on and complete the
.
L -scale item themielve*
.
Vour participation in thi*
evaluation of
our program
<*
very much appreciated.
BACKGROUND
INFORMATION:
Street
City
& State
.
VOUR MARITAL
STATUS
(Check one)
(1)
Currently married
(2)
Separated,
divorced,
widowed
(3)
Never married
Today's Date
Phone
17-22
SEX
(Check one)
(1)
Male
Female
25-26
EDUCATION
(Check one)
(1)
Less
than
high
school
(2)
High
school
graduate
(3)
Some
college
(4)
College
graduate
(Type of degree
HEIGHT:
WEIGHT:
inches
sounds
DO YOU SMOKE CIGARETTES?
(Check
one)
(1
)
Not
at
al
(2)
About
1/2
pack
per day
About
pack per day
Over
pack per day
HOW MUCH COFFEE
DO
YOU DRINK EACH DAY?
(Check one)
(1)
None or rare cup
(3)
(2)
About
1-2 cups per day
(4)_
DO
YOU WATCH TV?
(Check one)
(1
)
None
or
rarely
(4)
(2)
Less
than
hour per day
(5)~
(3)
1-2 hours
per day
AVERAGE HOURS OF SLEEP
PER NIGHT
(Check one)
(1
)
4-5 hours
(4)
(2)
5-6 hours
(5)~
(3)
6-7 hours
’
—
OCCUPATION OR
PROFESSION:
Approved For Release 2003/09/10
: CIA-RDP
3-4 cups
per day
5 or more
cups
per day
3-4
hours
per day
5 or more hours
per day
7-8 hours
or more hours
28-30
31-32