Skip to content

Client Portal

contact@shaylynnraymond.com

Shaylynn Hayes-Raymond

Become a Client
Info
Counselling
Misophonia Coaching
Cart
Cart

Shaylynn Hayes-Raymond

Become a Client
Info
Counselling
Misophonia Coaching
Cart

Misophonia Audit

Misophonia Coping Skills Audit

This form is for the misophonia coping skills audit.

Name(Required)

First Last

Email(Required)

What is your age?(Required)

How many people live in your home, including you?(Required)

If you live with others, please rate how willing they are to accommodate misophonia:(Required)

I do not live with others

Not willing to accommodate

Somewhat willing to accommodate

Willing to accommodate

Very willing to accommodate

Please describe the triggers you find most disturbing in your home environment.(Required)

Please describe what tools, adjustments, or coping skills you currently use to manage these triggers.(Required)

Please describe any social, cultural, or personal values that coincide with coping with misophonia (ie. prefer family dinners together, must sleep with partner, must stay in situations that are triggering).(Required)

How would you describe the area you live in?(Required)

Remote (no neighbors)

Rural (few neighbors)

Suburban (many neighbors but with yards)

Urban (city, with homes/buildings close together)

What type of environment do you live in?(Required)

Rental home/apartment

Owned home

With family or friends

Dorm room

Other (use next line)

Please describe your ability to make changes to this environment:(Required)

I have no ability to make changes to my environment

I can make small changes to my environment (put things on walls, move furniture, cover windows, etc)

Make some changes to the physical environment (all above + caulking windows, changing small features like cabinet harware, etc).

I can make construction changes (all above and, adding insulation, redoing windows, etc)

What would you consider your budget to be?(Required)

$0

$1-$100

$100-$500

$500-1000

$1000-$5000

$5000-$10000

If "other" please describe.

Provide photos of your home, rooms you frequent often, and area around your home.

Max. file size: 512 MB.

This is optional but can help provide more customized and fine-tuned suggestions.

Are you interested in coaching (worldwide) or counselling (canada) for misophonia coping skills and support?(Required)

Yes, I am interested in coaching (worldwide).

Yes, I am interested in counselling (Canada)

No, I am not.

What types of suggestions would you like to see in your report? (Please select all that apply)(Required)

I understand that this audit is provided on an information basis and is not a substitute for therapy.(Required)

I understand and consent.

Please sign below.

Signature(Required)

Billing is done through S. R. Wellness and Media, Shaylynn Hayes-Raymond's counselling license with the CCTNB is LCT-C24-039.