First Name*
Last Name *
Your Email *
Address*
City*
State*
Zip*
Home Phone*
Mobile Phone*
Business Phone
Date of birth

Sex

FemaleMale

Place of birth
Present Occupation? How long?

What is your level of development in metaphysics? Tick one.
BeginnerIntermediateAdvanced

Which area of the metaphysical are you most interested in?

Previous Training (List classes you have taken, if any.) Teacher/Location
Are you currently working as a practitioner? What area? Where? How long?
Are you currently teaching a metaphysical class? What class? Where? How long?

Level of Education:
High SchoolCollegeGraduate WorkOther

If you chose Other for Level of Education please explain here:
Within the last six months, have you taken (or has a health professional advised you to take) any prescription medications or drugs which: a) affect your mental process or mood; or b) treat a "chemical imbalance"? * (Please fill out)

YesNo

If yes, please specify:

Have you undergone psychotherapy/analysis?*
YesNo

Have you ever been hospitalized for mental breakdown or illness?*
YesNo

Have you had any seizures?*
YesNo

Do you have epilepsy?*
YesNo

Do you have any dislikes/intolerances?*

Participation in any other mind training activities (TM, Silva, Monroe Institute):*
YesNo

If yes, have you had any difficulties?
YesNo

If yes, please explain:
What specifically about this program motivates you to attend, and what benefits do you hope to receive?*
How did you find out about this program?*