Misophonia Treatment Forms

Here are the forms for individuals who want to receive treatment from Tom Dozier / Misophonia Treatment Institute.

Treatment worldwideYou can fill out these forms (including electronic signing) and save these PDF files.  Then email the files to tom@misophoniatreatment.com.

Please fill out each of these 8 forms using the free Adobe Reader.  Do not use Preview (Mac OS) because it corrupts the file.
1. Misophonia Assessment Questionnaire – Misophonia Assessment Questionnaire
2. Misophonia Emotional Responses – Misophonia Emotional Responses
3. Misophonia Coping Responses – Misophonia Coping Responses
4
. Misophonia History Questionnaire – Misophonia History Questionnaire
5. Misophonia Activation Scale – Misophonia Activation Scale
6. A-MISO-S (misophonia severity) – A-MISO-S
7. Detailed Trigger Inventory – Detailed Trigger Inventory
8. Misophonia Treatment Institute Patient Information – MTI Patient Information

Please fill out this form if you also want Parent Coaching to work on behavior concerns of your child.
9. Parent Coaching Enrollment Agreement (and guarantee) – GPT Enrollment Agreement

Email the completed forms to tom@misophoniatreatment.com.

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.