AUGUST 11, 1980 LETTER FROM GATEWAY COORDINATOR

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00788R001700210038-1
• Release Decision: RIPPUB
• Original Classification: K
• Document Page Count: 6
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 38
• Publication Date: August 11, 1980
• Content Type: LETTER

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
August 11, 1980
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 Aire-,,q,, 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-RDP96-00788ROO1700210038ClONFIDENTIAL
Monroe Institute of Applied Sciences
GATEWAY PROGRAM APPLICATION
1. NAME
Address
City State Zip
Home Phone
Present Occupation
Person in closest association with you: Name & Address
Date of Birth
Sex
Married _
Children _
2. EDUCATION
High School _
College
3. PHYSICAL
Height Weight
Any chronic illness, abnormalities, disabilities
Major illnesses, surgical operations or accidents
Presently on medication Special diet
For what reason
Recent physical. exam
Do you participate in s 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
Insects Animals
Heights Closeness
Events/things that please you most .-
(3) No Fear
Snakes -
Darkness
5. Participation in any other mind training activities: TM, Silva, etc.
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 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?
Session Fee Deposit Deposit refundable until
EXCURSION $ 55 $ 15 Two weeks before the session
WEEKEND - DISCOVERY 350.. 75. Four weeks before the session
EI .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 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
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 ADAP' fMd f gr6ftase 2003/09/10: CIA-Rnp9R-00788RO01700210038-1
6. Enjoyed talking with others.
7. Felt trusting of people.
R. Found work useful and interesting.
9. Been involved, interested in things.
10. Felt needed and useful.
DURING THE PAST MONTH, I'VE . 4
Some- Almost
Meaze anaweA each efiietement below) Rarely times Often Always
(- - _)
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:
(Please Print
A. SEX (Check one)
(1) Male
(2) Female
B. MARITAL STATUS (Check one)
(1) Currently married
(2) Separated, divorced,
or widowed
(3) Never married
Today's
Date:
Month Day Year
C. EDUCATION (Check one)
(1) Less than high school
(2) High school graduate
(3) Some college
(4) College graduate
D. AGE
P.lea.6e monk one anbwe2 ?on each que6.ti.on below.
Man.k youit anbwc i Like .th.i.a :
DURING THE PAST MONTH, HAVE YOU . .
(P.leaae aniwen, each quea.ti.on below)
1. Worried about something?
2. Felt gloomy, blue?
3. Been on edge, tense?
4. Felt uneasy, troubled?
5. Been unhappy?
Q
Answer Choices
1 2 3 4
Some-
Rarely times
Q
COPYRIGHT 1978 by IPEV Int'l.
Rep+wdw tion by any p'wcea6 without pehmi.aa.i.on v.iotatea copyn,ight .tows.
INSTITUTE FOR PROGRAM EVALUATION (IPEV Int'l)
Answer Choices
1 2 3
II
ARE YOU LIVING WITH A SPOUSE, PARENT, OR SOMEONE IN A CLOSE RELATI NSH ?
(1) No (If you marked "no", skip the next 5 questions)
(2) Yes (If you marked "yes", please answer the 5 questions below)
DURING THE PAST MONTH HAVE YOU AND
THIS PERSON spouse, parent, etc.
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 Choices
1 2 3
Same-
Rarely times Often
oil
-7
(1) No (If you marked "No", skip to Question 21 on reverse side)
(2) -Yes (If you marked "Yes", please answer the next 5 questions)
DURING THE PAST MONTH, HAVE YOU AND THE
CHILDREN . . . .
16.
17.
18.
19.
20.
Spent time talking with each other?
Spent time doing things together?
Treated each other with respect?
Felt close to each other?
Done things for each other?
Box 4654, Roanoke, Va. 24015 Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210038-1
Answer Choices
2 3
ri
Some-
times
II
4
most
Always
LI
Peer SRN tnw an rtPUeaa Aida
 CPYRGHT
Approved d ekM!gs2003/09/410
Some-
Rarely 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?
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
Not
Once
Answer Choices
2 3 4
1-2 Times 1-2 Times most
per MONTH per WEEK Daily
Q
DURING THE LAST MONTH . . . .
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?
Answer Choices
1 2 3 4
Not 1-2 Times 1-2 Times Almost
Once per MONTH per WEEK Daily
CID ~PR06L~I~SCTi4z EAS OFINDICATEADJUSTMENT ACTIVITYODURING
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
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 or Release
- - -
BACKGROUND INFORMATION TO PAL SCALE
Fnom time to #.ime, people become -cnuot-ved in expenienee,s that may .change the-i4
#i.ve% in cen.tan ways. The attached .5cate pnovides in6onmation on youii. PROFILE OF
ADAPTATION TO LIFE (PAL), and wiJ be used only to meaeuAe the e66ect6 06 ow[ pn.o-
gnamns oven time. The in6onmation you pnov.i.de wAU hemain 6titictQ,y con6identi,at and
the nehutts wife be nepon.ted in gn.oup avehage6. You, o6 counde, ane 6,kee not to
panti,c,ipate c -that is youh choice.
P~eaee eomptete .thus backgnvund .in6onmat4ion 6L'rst. Then go on and wmp.Cete the
PAL Scale -i,temms -them.5ei've3. Youh pa tici,pati,on in -thin evittuation o6 oun pnogham
- vent' much appneci.a.ted.
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
SEX (Check one)
(1 ) Male (2)
Female
24
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)
(1) None or rare cup
)
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
(5)
8 or more hours
(3) 6-7 hours
OCCUPATION OR PROFESSION:
37
Approved For Release 2003/09/10 : CIA-RDP96-0078 '0038_1
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