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 and save these PDF files. Then email the files to tom@misophoniatreatment.com.

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
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. 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 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.

How to save a filled form completed in Chrome browser:

  1. Complete the form.
  2. Click the PRINT icon
  3. Select CHANGE for the Destination
  4. Select “Save as PDF” or another PDF option
  5. Click SAVE in the Print section
  6. Specify the file location (where you can find it) and file name

See the images below.

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