FORM: MPI-01-2001
REV: 3.7
DATE: 11.03.01
MEMORY PALACE INSTITUTE
VOLUNTARY SUBJECT INTAKE FORM
Form MPI-01 :: Revision 3.7 :: November 2001
IMPORTANT: This form must be completed in its entirety before your first session. All information provided will be used to create your personalized memory enhancement profile. Incomplete or inaccurate information may result in suboptimal results or unexpected side effects.
PERSONAL INFORMATION
Full Legal Name: *
Date of Birth: *
Age:
Social Security Number:
Current Address: *
Emergency Contact:
MEMORY ASSESSMENT
Earliest Childhood Memory:
Most Vivid Memory:
Memory Concerns:
Family Memory History:
ENHANCEMENT GOALS
Primary Objectives:
Desired Enhancement Level:
MEDICAL HISTORY
Current Medications:
Medical Conditions:
Allergies or Reactions:
IMPORTANT NOTICE: Enhancement procedures may cause temporary disorientation, vivid dreams, or difficulty distinguishing between enhanced and original memories during the adjustment period. These effects typically resolve within 72 hours of each session.
REFERRAL INFORMATION
How did you learn about our services?
Referring Professional:
INFORMED CONSENT AND ACKNOWLEDGMENT
I acknowledge that I have been informed of the following:
1. Memory enhancement procedures are experimental and results may vary between individuals.
2. Some subjects may experience temporary confusion, disorientation, or false memory formation during the adjustment period.
3. Enhanced memories may feel more vivid than natural memories and could potentially affect my perception of past events.
4. The Institute reserves the right to archive memory extractions for research purposes.
5. I may experience dreams or recollections that do not correspond to my actual life experiences.
6. Withdrawal from the program is permitted at any time during the orientation phase (first 3 sessions).
7. After completion of Phase 3, memory modifications become permanent and cannot be reversed.
8. I understand that some subjects report difficulty distinguishing between original and enhanced memories.
9. The Institute is not responsible for psychological effects resulting from recovered suppressed memories.
10. All sessions are monitored and recorded for quality assurance and research purposes.
Subject Signature: Date:
Print Name:
Witness Signature: Date:
Staff Member: ID#:
FOR OFFICE USE ONLY:
Subject ID: MK-____ | Intake Date: _______ | Staff Initial: _____ | Clearance Level: _____
Initial Assessment: _________________ | Phase Assignment: _______ | Special Notes: _________________
Form generated: September 20, 2025 at 01:35:27 PM | Version: 3.7 | Next revision due: December 15, 2001