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Selective Mutism Questionnaire (SMQ)
Today's Date
*
+
Date of Child's Upcoming SMart Center Appointment
+
First Name of Child
*
Last Name of Child
*
Completed by (Parent/Guardian) First & Last Name
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Email Address
Phone Number
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.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
2. When appropriate, my child talks to selected peers (his/her friends) at school.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
3. When my child is asked a question by his/her teacher, s/he answers.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
4. When appropriate, my child asks his or her teacher questions.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
5. When appropriate, my child speaks to most teachers or staff at school.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
6. When appropriate, my child speaks in groups or in front of the class.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
WITH FAMILY
1. When appropriate, my child talks to family members living at home when other people are present.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
2. When appropriate, my child talks to family members while in unfamiliar places.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
3. When appropriate, my child talks to family members that don't live with him/her (e.g. grandparent, cousin).
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
4. When appropriate, my child talks on the phone to his/her parents and siblings.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
5. When appropriate, my child speaks with family friends who are well known to him/her.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
6. When appropriate, my child speaks to at least one babysitter.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)
1. When appropriate, my child speaks with other children who s/he doesn't know.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
2. When appropriate, my child speaks with family friends who s/he doesn't know.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
3. When appropriate, my child speaks with his or her doctor and/or dentist.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
4. When appropriate, my child speaks to store clerks and/or waiters.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
5. When appropriate, my child talks when in clubs, teams, or organized activities outside of school.
Always
Often
Seldom
Never
N/A
-
Always
Often
Seldom
Never
N/A
INTERFERENCE/DISTRESS
How much does not talking interfere with school for your child?
Not at all
Slightly
Moderately
Extremely
-
Not at all
Slightly
Moderately
Extremely
How much does not talking interfere with family relationships?
Not at all
Slightly
Moderately
Extremely
-
Not at all
Slightly
Moderately
Extremely
How much does not talking interfere in social situations for your child?
Not at all
Slightly
Moderately
Extremely
-
Not at all
Slightly
Moderately
Extremely
Overall, how much does not talking interfere with life for your child?
Not at all
Slightly
Moderately
Extremely
-
Not at all
Slightly
Moderately
Extremely
Overall, how much does not talking bother your child?
Not at all
Slightly
Moderately
Extremely
-
Not at all
Slightly
Moderately
Extremely
Overall, how much does your child's not talking bother you?
Not at all
Slightly
Moderately
Extremely
-
Not at all
Slightly
Moderately
Extremely
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.