Child’s Name:____________________________ Today’s Date:_______________________

EXPRESS Selective Mutism (SM) Communication Questionnaire

Child’s date of birth:_________________________ Child’s grade in school:__________________

Gender of child: Female____ Male____

Name of person completing form:_________________________ Relationship:____________________

Language spoken at home by parents:___________________ and child: _________________________

Is child bilingual: NO____ or YES____ - Please indicate languages spoken fluently: _________________

Has your child received a formal diagnosis of selective mutism? YES____ NO____ NOT SURE ____

If yes, when diagnosed with SM (year) _______________ and by whom ________________________.

Diagnosis, Symptoms, and Treatment:

Has your child ever received any other diagnosis (listed below)? If treatment was provided, list dates.
Indicate any symptoms you have observed. Check all that apply.
Diagnosed Received Even if no formal diagnosis,
(Year) treatment list symptoms observed

Development delay: ___________ ________ ______________________

Speech-language impairment: ___________ ________ ______________________

Sensory sensitivity: ___________ ________ ______________________

Auditory processing issues: ___________ ________ ______________________

Learning Disorder /Difference: ___________ ________ ______________________

Anxiety Disorder: ___________ ________ ______________________

Medical Conditions: ___________ ________ ______________________

Attention Deficit Disorder: ___________ ________ ______________________

Hyperactivity Disorder: ___________ ________ ______________________

Other(s): ___________ ________ ______________________

Questions about selective mutism:

When were you first made aware of your child’s mutism? __________________ (age)

In what situation(s) was it noticed? _____________________________________________________

__________________________________________________________________________________.

Evelyn R. Klein & Sharon Lee Armstrong, 2015 Page 1

Child’s Name:____________________________ Today’s Date:_______________________

Please describe your child’s temperament / disposition around different people at home, school, and in
public places.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________.

Is there a history of social anxiety, other anxiety problems, or phobias in the immediate or extended
family? YES____ NO____

If yes, please explain:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
___________________________________________________________________________.

In the box below, please describe what you might say or do to help your child communicate in various
settings (at home, in school, and in public places).

Communication in various settings:

On next page: In the 3 settings listed on the chart below (home, school, and public places), please
indicate how your child communicates with those listed. Write a sentence or two to describe the ways
in which your child communicates with others. In situations where your child has had no opportunity to
meet and interact with those people or situations listed below, write NA for “Not Applicable.” Also,
indicate if your child only responds or responds and initiates. Please note if child whispered, spoke in
single words, used sentences, or engaged in spontaneous conversation. Also note if nonverbal using
gestures or communicating by writing.

Evelyn R. Klein & Sharon Lee Armstrong, 2015 Page 2

Child’s Name:____________________________ Today’s Date:_______________________

Evelyn R. Klein & Sharon Lee Armstrong, 2015 Page 3

Child’s Name:____________________________ Today’s Date:_______________________

WRITE IN BOXES Home School Public

HOME SCHOOL PUBLIC
Servers
Not Applicable Not Applicable How does your child
communicate with a server at a
restaurant?

X X
____responds / ____initiates
If a helping professional (such as If a helping professional (such How does your child
Doctors / a therapist or counselor, etc.) as nurse, counselor, etc.) is communicate with a doctor or
Helping worked with your child at home, working with your child at other helping professional at
how did your child school, how does your child their office?
Professionals communicate? communicate?

____responds / ____initiates ____responds / ____initiates ____responds / ____initiates

When a peer visits the home, How does your child When in a public place with a
Peers how does your child communicate with peers at peer (and a parent), how does
communicate with him/her? school? Consider one peer, your child communicate? How
small group, and classroom? does your child communicate if
playing at a peer’s house?

____responds / ____initiates ____responds / ____initiates

____responds / ____initiates

If a teacher visits the home, How does your child If a teacher is seen in a public
Teachers how does your child communicate with teachers place, how does your child
communicate with him/her? in school when alone with the communicate with him/her?
teacher or in the group?

____responds / ____initiates ____responds / ____initiates ____responds / ____initiates

Evelyn R. Klein & Sharon Lee Armstrong, 2015 Page 4

Child’s Name:____________________________ Today’s Date:_______________________

Others

____responds / ____initiates ____responds / ____initiates ____responds / ____initiates

How does your child communicate in various settings when you are there compared to when you are
not there? Please describe.

How does your child communicate on the phone with anyone who may call? Please describe.

How does your child like school? Please describe.

Has your child ever received any type of treatment / therapy / medication for selective mutism? If
yes, please explain your child’s progress and difficulties.

Evelyn R. Klein & Sharon Lee Armstrong, 2015 Page 5

Child’s Name:____________________________ Today’s Date:_______________________

As best you can, please provide an overview of your child’s selective mutism and any information you
believe important to share. In doing so, please provide details of your child’s social world and
communication skills and difficulties. Include anything your child has told you about talking including
what helps or what is difficult.

Evelyn R. Klein & Sharon Lee Armstrong, 2015 Page 6