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Please consider your child's behavior in the last two weeks and rate how frequently each statement is true for your child.

AT SCHOOL

1. When appropriate, my child talks to most peers at school.
 AlwaysOftenSeldomNeverN/A
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2. When appropriate, my child talks to selected peers (his/her friends) at school.
 AlwaysOftenSeldomNeverN/A
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3. When my child is asked a question by his/her teacher, s/he answers.
 AlwaysOftenSeldomNeverN/A
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4. When appropriate, my child asks his or her teacher questions.
 AlwaysOftenSeldomNeverN/A
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5. When appropriate, my child speaks to most teachers or staff at school.
 AlwaysOftenSeldomNeverN/A
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6. When appropriate, my child speaks in groups or in front of the class.
 AlwaysOftenSeldomNeverN/A
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WITH FAMILY

1. When appropriate, my child talks to family members living at home when other people are present.
 AlwaysOftenSeldomNeverN/A
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2. When appropriate, my child talks to family members while in unfamiliar places.
 AlwaysOftenSeldomNeverN/A
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3. When appropriate, my child talks to family members that don't live with him/her (e.g. grandparent, cousin).
 AlwaysOftenSeldomNeverN/A
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4. When appropriate, my child talks on the phone to his/her parents and siblings.
 AlwaysOftenSeldomNeverN/A
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5. When appropriate, my child speaks with family friends who are well known to him/her.
 AlwaysOftenSeldomNeverN/A
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6. When appropriate, my child speaks to at least one babysitter.
 AlwaysOftenSeldomNeverN/A
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IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)

1. When appropriate, my child speaks with other children who s/he doesn't know.
 AlwaysOftenSeldomNeverN/A
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2. When appropriate, my child speaks with family friends who s/he doesn't know.
 AlwaysOftenSeldomNeverN/A
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3. When appropriate, my child speaks with his or her doctor and/or dentist.
 AlwaysOftenSeldomNeverN/A
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4. When appropriate, my child speaks to store clerks and/or waiters.
 AlwaysOftenSeldomNeverN/A
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5. When appropriate, my child talks when in clubs, teams, or organized activities outside of school.
 AlwaysOftenSeldomNeverN/A
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INTERFERENCE/DISTRESS

How much does not talking interfere with school for your child?
 Not at allSlightlyModeratelyExtremely
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How much does not talking interfere with family relationships?
 Not at allSlightlyModeratelyExtremely
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How much does not talking interfere in social situations for your child?
 Not at allSlightlyModeratelyExtremely
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Overall, how much does not talking interfere with life for your child?
 Not at allSlightlyModeratelyExtremely
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Overall, how much does not talking bother your child?
 Not at allSlightlyModeratelyExtremely
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Overall, how much does your child's not talking bother you?
 Not at allSlightlyModeratelyExtremely
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Bergman, R.L, Keller, M.L., Piancentini, J., & Bergman, A.J. (2008). The development and spychometric properties of the Selective Mutism Questionnaire. Journal of Clinical Child and Adolescent Psychology.