Here are the forms for individuals who want to receive treatment from Tom Dozier / Misophonia Treatment Institute.
You can fill out these forms (including electronic signing) and save these PDF files. Then email the files to [email protected].
Please fill out each of this form packet using the free Adobe Reader. Do not use Preview (Mac OS) because it corrupts the file.
1. Misophonia Assessment Documents– Misophonia_Assessment_Documents-9
Please fill out this form if you also want Parent Coaching to work on behavior concerns of your child.
– Parent Coaching Enrollment Agreement – GPT_Client_Information
Email the completed forms to [email protected].
If you have problems filling out these forms electronically, you can print them and fill them out. Then email a scanned PDF of the forms or good pics.