Selective Mutism Questionnaire (SMQ)

Selective Mutism Questionnaire (SMQ)

Selective Mutism Questionnaire (SMQ)
Patients Name:

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

	Always	Often	Seldom	Never
1. when appropriate, my child talks to selected peers (his/her friends) at school.
2. When appropriate, my child talks to most peers at school.
3. When my child is asked a question by his/her teacher.
4. When appropriate , my child asks his or her teacher questions.
5. When appropriate, my child speaks to most teachers or staff at school.
6. When appropriate, my child speaks in groups or in front of the class.

Home/Family

	Always	Often	Seldom	Never
7. when appropriate, my child talks to family members at home when other people are present.
8. When appropriate, my child talks to family members while in unfamiliar places.
9. When appropriate, my child talks to family members that don't live with him/her (e.g. grandparent, cousin.)
10. When appropriate , my child talks on the phone to his/her parents or siblings.
11. When appropriate, my child speaks with family friends who are well-known to him/her.
12. My child speaks to at least one babysitter.

In social Situations (Outside of School)

	Always	Often	Seldom	Never
13. when appropriate, my child speaks with other children who she/he doesn't know.
14. When appropriate, my child speaks with family friends who she/he doesn't know.
15. When appropriate, my child speaks to store clerks and/or waiters.
16. When appropriate , my child speaks with his or her doctor and/or dentist..
17. When appropriate, my child talks when in clubs, teams or organized activities outside of school.

Interference/Distress*

	Not at all	Slightly	Moderately	Extremely
18. How much does not talking interfere with school for your child?
19. How much does not talking interfere with family relationships?
20. How much does not talking interfere in social situations for your child?
21. Overall , how much does not talking interfere with life for your child?
22. Overall, how much does not talking bother your child?
23. Overall, how much does your child's not talking bother you?

Scoring: Always = 3; Often = 2; Seldom = 1; Never = 0

* These items are not included in the total score and are for clinical purposes only.
Should be Empty: