Provider Application

If you’re interested in becoming a Misophonia provider, please fill out an application. You will hear back shortly.

To Become a Level 1 Misophonia Provider please have the following:

accreditation in one of the listed fields
attend 1 Misophonia Webinar through www.misophoniawebinar.com. These webinars are hosted by Dr. Jennifer Jo Brout of the IMRN. Please attach proof of attendance to your submission.

Name*
First Last
Phone*
Email*
Professional Degrees
Where are you licensed to practice?*
State / Province / Region Country
Qualifications
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

This is necessary to add you to the map.
Please Provide Your Biography
Provide your biography for your listing. Also include any websites, social media pages, etc that you'd like included. Please do not double space after periods.
Photo of Yourself
Please provide a photo for your listing.
Have you attended an e-class from www.misophoniawebinar.com?*
- Yes
- No, But I am Going To
Please note, courses that are not listed are not eligible.
What email did you sign up for the webinar with?*

Please ensure you are using the correct email that you signed up for the webinar with, as we need to confirm you attended.

Misophonia Providers