Here are the forms for individuals who want to receive treatment from Tom Dozier / Misophonia Treatment Institute.
You can open all 9 forms (combined) and then download/save them. WARNING – You must download/save the file, then open it on your computer. If you fill them out first, your information will be lost when you download/save the file. If you fill out the forms in a browser, you can “print to PDF” to save the completed form to your computer.
Download ALL FORMS here: All Misophonia Treatment Forms
Please download fill out each of these 9 forms using the free Adobe Reader. Do not use Preview (Mac OS) because it corrupts the file. If you use Preview, please print the completed form as a PDF and sent that 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
9. Misophonia Impact Survey – Misophonia Impact Survey
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 firstname.lastname@example.org.
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.
How to save a filled form completed in Chrome browser:
- Complete the form.
- Click the PRINT icon
- Select CHANGE for the Destination
- Select “Save as PDF” or another PDF option
- Click SAVE in the Print section
- Specify the file location (where you can find it) and file name
See the images below.