Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210038-1 AU9USt 11, 1980 Dear Fred, The Advanced Reunion Gateway Sessio-n for your Graduate Group is scheduled for September 20-28F 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 includ es food and housing, plus three Master Mind cassettes to take home and use. I will hold a place for you until Alre;,ay 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-RDP96-0-0788ROO1700210038-1 11 1 N Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210038 CPYRGHT 6NFIDENTIAL Monroe Institute of Applied Sciences GATEWAY PROGRAM APPLICATION 1. NAME Address City State Zip Home Phone Business Phone Present Occupation Person in closest association with you; Name & Address Date of Birth Sex Married Children Phone 2. EDUCATION High School College 3. PHYSICAL Height Any chronic illness, abnormalities, disabilities Major illnesses, surgical operations or accidents Presently on medication Recent physical. exam Do you participatej@ns Exercise daily Are you right or left handed 4.MENTAL Have you undergone psycho-therapy /analysis 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-RDP96-00788ROO1700210038-1 Graduate Work Other Weight Special diet For what reason What type General health How long Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210038-1 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 WEr-KEND - DISCOVERY 350.. 75. Four weeks before the session EIGHT .DAY 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 t.hat 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 oMaster Charge oVISA. Card No. exp. date Signed Date Send to: MONROE INSTITUTE OF APPLIED SCIENCES P. 0. BOX 94C FABER, VIRGINIA 22938 (804) 361-1252 Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210038-1 CPYRGHT d ase 2003109110: CI A-R D1246-MUKUKUM fuVA-19u,30- I PROFILE OF ADAp fdr6 WfdA ;t Answer C hoices 1 2 3 4 DURING THE PAST MONTH, I'VE Some- - -Almost Mea6e an6weA each 4&tement betow) Rarely times Often Always 6. Enjoyed talking with others. INSTRUCTIONS: SU61--i- 7. Felt trusting of People. 1. Before answering the questions below, please read the information provided to you about the purpose of this questionnaire, protection S. Found work useful and interesting. of your right to privacy, etc. 9. Been involved, interested in things. R 2. Try to answer each question below to the best of your ability. Do fi t im lse is Y ti 10 Felt needed and useful our rs on. pu not spend too much time on any one ques . . generally your best answer. PLEASE COMPLETE THE FOLLOWING BACKGROUND INFORMATION: Your Today's ARE YOU LIVING WITH A SPOUSE, PARENT, OR SOMEONE IN A CLOSE RELATIONSH M- No (If you marked "no", skip the next 5 questions) IP? Date: Name: (2) Yes (If you marked "yes", please answer the 5 questions below) (Please Print) Month. Day Year A. SEX (Check one) Male (1) (2)- Female B. MARITAL STATUS (Check one) (1) Currently married (2!)= Separated, divorced, or widowed (3)- Never married C. EDUCATION (Check one) (1) Less than high school (2)- High school graduate (3) Some college (4)' College graduate D. AGE DURING THE PAST MONTH, HAVE YOU AND THIS PERSON (spouse, parent, etc.) Answer Choices 1 1 2 3 4 Some- Almost Rarely times Often Always PteaAe ma&k anz an6uw-x Jo)L each queAtion betow. Maxk youit an,6wA tike thi6: [7v ox DURING THE PAST MONTH, HAVE YOU . . . Mea6e anAwe& each queAtion betow) 1. Worried about something? 2. Felt gloomy, blue? 3. Been on edge, tense? 4. Felt uneasy, troubled? 5. Been unhappy? 1 Answer unoices 2 3 Never Rarely Scme- times Often COPYRIGHT 1978 by IPEV Int'l. Repotoduetion by any )xoceA,6 wLthout peft"4ion v@DtAtz6 copyxight tau*. 11. Been able to talk it through when angry? 12. Spent enjoyable times together? 13. Discussed important matters? F] 19 14. Felt close to each other? 15. Agreed about social activities and friends? ARE THERE CHILDREN WHERE YOU LIVE? (Mark onei M- No (If you marked "No", skip to Question 21 on reverse side) (2)_-Yes (If you marked "Yesn, please answer the next 5 questions) 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? Answer Choices 1 2 3 4 Rarely Some- times OfteA Almost' Always El =1 INSTITUTE FOR PROGRAM EVALUATION (IPEV Int'l) Box 4654, Roanoke, Va. 24015 Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210038-1 CPYRGHT Appfoved DURING THE PAST MONTH, HAVE YOU . . . Rarely 21. Had enough money to handle unexpected expenses? 22. Had enough money to pay your bills? 23. Been free from worry about debts? 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? 1 Answer Choices 2 3 4 Not Once 1-2 Times per MONTH 1-2 Times per WEEK Almost Daily DURING THE LAST MONTH . . . . Once 31. Have you used alcohol or non prescription drugs? F@ 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? Answer unoices 2 3 4 1 1-2 Times 1-2 Times Almost per MONTH per WEEK Daily F-1 El INDICATE WHETHER OR NOT YOU HAVE CIN-19069WAAMMI-EASU 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) No problem (1) (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 M_ No problem (2) Some problem (3)- Serious problem 39. With Having Enough Money to Handle Expenses? (1)_ No problem (2)_ Sane problem (3)- Serious problem 40. With Feeling Sick, or Problems with Health? (1)_ 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 Approved For Release 2003/09/10 CIA-RDP96-00788 R001700210038-1 CPYRGHT BACKGROUND INFORMATION TO PAL SCALE Ftom t,@mc to time, peopte become invot-ved in expexiencez that may change theik' ZivC6 in cetta@'n tvays. The attached .6cate ptovides in6otmation on you'k PROFILE OF ADAPTATION TO LIFE (PAL), and wiU be uzed onZy to mea.6uAe the e66ect6 o6 out pko- 9@Lam,6 oveA time. The in6o@unation you p@Lovide witt temain 6t4ictty con6identiat and the Auutt6 witt be kepotted in gAoup avetage,6. - You, o6 couAze, OAe 6,kee not to patticipate .1-'6 tAat i6 youA choice. P@ea,5e comptete tki.6 backgtound in6otmation 6iAst. Then go on and comptete the PAL Scae C'tem,5 them,6eive,6. YouiL paAticipation in thiz evatuation o6 ouA piLogkarn Z6 ve,,Ly much app@Lec,4-'ated. 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 worried 23 SEX (Check one) 0 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 I pack per day. (2)- About 1/2 pack per day (4) Over I pack per day 33 HOW MUC H COFFEE DO YOU DRINK EACH DAY? (Check one) (1) None or rare cup (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) 0 ) None or rarely (4) 3-4 hours per day (2) Less than I 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 (5) - 8 or more hours (3)-- 6-7 hours 36 OCCUPAT ION OR PROFESSION: 37 Approved For Release 2003/09/10 CIA-RDP9E 7VM10038-1 3(80) Prog. Sub.i