Shining Star Questionnaire

We are so delighted to feature you or your child as a SMart Center Shining Star. Your story will inspire hope for other SM families! Please complete the form below with as much information you are comfortable with. For reference, please puruse our Shining Star Success Stories.

Patient's First & Last Name *

Contact Email *

How old were you (or your child) when you first noticed/realized you (or your child) were mute in select social settings? *

Please briefly summarize where/when you (or your child) was mute/not mute (2-3 sentences is fine!) *

Were you (or your child) in treatment for Selective Mutism, Social Anxiety, or related disorders before finding the SMart Center? If yes, where? *

What brought you to seek treatment at the SMart Center? *

What SMart Center services did you (or your child) use? Select all that apply: *

How often do/did you consult with the SMart Center? *

How has your life changed? What have you noticed? What's different at school? At home? With friends and extended family? *

What S-CAT® strategies helped the most? What makes S-CAT® treatment different from other methods you may have tried? *

What's your advice for parents or individuals with SM? *

Are you willing to share a brief sentence or two about your overall thoughts on treatment and overcoming Selective Mutism?

Can we use you (or your child's) name? If not, we are happy to use an alias! *

Yes, you can use my child's first name

No, please use an alias

Please upload a picture of you or your child BEFORE treatment. Videos are acceptable too! If you don't feel comfortable sharing photos, we can use stock images. *

Please upload a picture of you or your child AFTER treatment. Videos are acceptable too! If you don't feel comfortable sharing photos, we can use stock images. *

Would you like to serve as a reference for families looking to speak with parents who have been through SMart Center program(s)? If yes, we will only supply your email address. *

Yes

No