CIA-RDP96-00788R001700210038-1

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Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
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August 11, 1980
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Dear Fred,
The Advanced Reunion Gateway Session for your Graduate
Group is scheduled for
September 20-28, 1980
It will be a time not only to renew old friendships,
but to be the first to experience the new Master Mind series.
There also will be special exploration exercises just for
Gateway Graduates, available only at the Institute.
The registration fee for Graduates is $725, or $650 if
you now are an Institute Sustaining Member. This includes
food and housing, plus three Master Mind cassettes to take
home and use.
I will hold a place for you until
Already reserved
so do phone or write me before then if you can come. Space
is limited, and I can't promise room for you beyond that
date. Please let me hear from you soon.
Love,
Alice Durrett
Gateway Coordinator
AD/gg
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1

CPYRGHT
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
CONFIDENTIAL
Monroe Institute of Applied Sciences
GATEWAY PROGRAM APPLICATION
1. NAME
Address
Date of Birth
City
State
Zip
Sex
Home Phone
1
1
Married
Business Phone
1
Children
Present Occupation
Person in closest association with you: Name & Address
Phone
1
1
2. EDUCATION
High School
Graduate Work
College
Other
3. PHYSICAL
Height
Weight
Any chronic illness, abnormalities, disabilities
Major illnesses, surgical operations or accidents
Presently on medication
Special diet
Recent physical exam
For what reason
Do you participate in sports
What type
Exercise daily
General health
Are you right or left handed
4. MENTAL
Have you undergone psycho-therapy/analysis
How long
Name and address of therapist
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
Snakes
Crowds
Heights
Closeness
Darkness
Other
Events/things that please you most
5. Participation in any other mind training activities: TM, Silva, etc.
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
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
$ 15
Two weeks before the session
WEEKEND - DISCOVERY 350. .
75.
Four weeks before the session
EIGHTY EXPLORATIONS
850.
200.
Six weeks before the session
(Fee varies with location)
I desire to participate in the following type of session
It is scheduled to be held at
THE CENTER
on 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 o 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-RDP96-00788R001700210038-1

CPYRGHT
PROFILE OF ADAPTATION TO LIFE
Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
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.
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:
Your
Name:
Today's
Date:
(Please Print)
Month
Day
Year
A. SEX
(Check one)
(1)
Male
(2)
Female
B. MARITAL STATUS (Check one)
(1)
Currently married
(2)
Separated, divorced,
or widowed
D.
AGE
(3)
Never married
Please mark one answer for each question below.
Mark your answer like this:
or
X
Answer Choices
1
2
3
4
DURING THE PAST MONTH, HAVE YOU .
(Please answer each question below)
Never
Rarely
Some-
times
Often
COPYRIGHT 1978 by IPEV Int'l.
Reproduction by any process without permission violates copyright laws.
INSTITUTE FOR PROGRAM EVALUATION (IPEV Int'1)
Box 4654, Roanoke, Va. 24015
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
1
Answer Choices
2
3
Rarely
Some-
times
Often
4
Almost
Always
6. Enjoyed talking with others.
7. Felt trusting of people.
8. Found work useful and interesting.
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)
(2)
No
( If you marked "no", skip the next 5 questions)
Yes (If you marked "yes", please answer the 5 questions below)
DURING THE PAST MONTH, HAVE YOU AND
THIS PERSON (spouse, parent, etc.) . .
1
Answer Choices
2
3
4
Almost
Always
Il. 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 ?
ARE THERE CHILDREN WHERE YOU LIVE? (Mark one)
(1)
No
( If you marked "No", skip to Question 21 on reverse side)
.Yes (If you marked "Yes", please answer the next 5 questions)
DURING THE PAST MONTH, HAVE YOU AND THE
CHILD (REN)
7
Answer Choices
2
3
Rarely
Some-
times
Often
4
Almost
Always
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?
Rarely
Some-
times
Often
(2)
1. Worried about something?
2. Felt gloomy, blue?
3.
Been on edge, tense?
4.
Felt uneasy, troubled?
5.
Been unhappy?
C.
EDUCATION (Check one)
(1)
Less than high school
(2)
High school graduate
(3)
Some college
(4)
College graduate
DURING THE PAST MONTH, I'VE .
( Please answer each statement below)
Please continue on reverse side

CPYRGHT
Approved FOR Release 2003/09/10
DURING THE PAST MONTH, HAVE YOU
.
Rarely
Some-
times
Usually
Always
21. Had enough money to handle
unexpected expenses ?
22. Had enough money to pay your bills?
23. Been free from worry about debts?
CIXIRDE 8556UN8815TH BELOW ASK THAT YOU INDICATE WHETHER OR NOT YOU HAVE
'EXPERIENCED ANY PROBLEMS IN CERTAIN AREAS 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 problem
(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)
No problem
(2)
Some problem
(3)
Serious problem
Answer Choices
2
4
3
DURING THE LAST MONTH
1
Not
Once
1-2 Times
per MONTH per WEEK
1-2 Times
Almost
Daily
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?
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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?
1
Answer Choices
2
3
4
DURING THE LAST MONTH, HAVE YOU
. .
Not
Once
1-2 Times 1-2 Times
per MONTH per WEEK
Almost
Daily
24. Had headaches?
41.
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

CPYRGHT
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
BACKGROUND INFORMATION TO PAL SCALE
From time to time, people become involved in experiences that may change their
lives in certain ways. The attached scale provides information on your PROFILE OF
ADAPTATION TO LIFE (PAL), and will be used only to measure the effects of our pro-
grams over time. The information you provide will remain strictly confidential and
the results will be reported in group averages. ' You, of course, are free not to
participate if that is your choice.
Please complete this background information first. Then go on and complete the
PAL Scale items themselves. Your participation in this evaluation of our program
is very much appreciated.
BACKGROUND INFORMATION:
Name
Today's Date
17-22
Street
Phone
City & State
Zip
YOUR MARITAL STATUS (Check one)
(1)
Currently married
(2)
Separated, divorced, widowed
(3)
Never married
23
SEX
(Check one)
(1)
Male
(2)
Female
24
AGE
25-26
EDUCATION (Check one)
(1)
Less than high school
(3)
Some college
(2)
High school graduate
(4)
College graduate
(Type of degree
)
27
HEIGHT:
feet
inches
28-30
WEIGHT :
pounds
31-32
DO YOU SMOKE CIGARETTES? (Check one)
(1)
Not at all
(3)
About 1 pack per day
(2)
About 1/2 pack per day
(4)
Over 1 pack per day
33
HOW MUCH COFFEE DO YOU DRINK EACH DAY?
(Check one)
(3)
3-4 cups per day
(2)
About 1-2 cups per day
(4)
5 or more cups per day
34
DO YOU WATCH TV? (Check one)
(1)
None or rarely
(4)
3-4 hours per day
(2)
Less than 1 hour per day
(5)
5 or more hours per day
35
(3)
1-2 hours per day
AVERAGE HOURS OF SLEEP PER NIGHT
(Check one)
(1)
4-5 hours
(4)
7-8 hours
(2)
5-6 hours
(3)
6-7 hours
(5)
8 or more hours
36
OCCUPATION OR PROFESSION:
37
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700310038-1
Prog.
Subj #
3(80)
(1)
None or rare cup