All questions on this form are considered required, meaning you will not be able to move forward in the Brief SMCDQ if you do not answer a question. If you do not feel a question relates to your child or you are not comfortable answering the question, please put "N/A" if it is a free response question, or select "No," or "None," if it is a check box/radio button question.

Brief SMCDQ

The Brief SMCDQ is used to help in the evaluation of the child with symptoms of Selective Mutism to help develop a diagnosis and treatment plan for the home, real world and school.

Demographic Information

Child's First Name *

Child's Last Name: *

Child's Date of Birth (MM/DD/YYYY) * 🛈 +

Child's Age: *

Child's Sex *

Child's Race/Ethnicity *

Child's Grade in School *

Parents' Names *

Parents' Primary Phone Number *

Parents' Secondary Phone Number *

Best Email Address to Reach Parents *

Home Address *

This material is part of Dr. Elisa Shipon-Blum’s Social Communication Anxiety Treatment® (S-CAT)® and is used under license.