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🏠
About Me
Clinical Qualifications
Publications & Appearances
Insurance
Payment Policy
Psychology Today Blog
Substack Blog
Therapy
Service Prices
Video Therapy
Voice Therapy
Chat Therapy
Email Therapy
Video Game Therapy
Insurance
FAQ
Specialties
General Therapy
Misophonia Therapy
OCD Therapy
Autism Therapy
ADHD Therapy
MATTERS™ Approach
CBT-MISO™
Misophonia
Misophonia 1-on-1 Sessions
Misophonia Parent Coaching
Couple’s Coping Sessions
Free Misophonia Resources
Training
Speaking
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: 64 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)
Environment suggestions Only (sound treating, sound masking, etc)
Coping skills and tools suggestions (products to use, cognitive/sensory based tools)
Both environment suggestions and coping skills and tools suggestions (all of the above)
I am not sure, please provide what you feel is necessary
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)
Your Name
Your Name
Your Name
Your Name
Ready to get started or have more questions? Fill out the form and I'll message you as soon as I can!
