School Speech Questionnaire*
Name of Teacher Who Completed This Questionnaire:
When responding to the following items, please consider the behavior of
your student, __________________, and activities of the past month and
rate how often each statement is true.
1. When appropriate, this student talks to most peers at school.
Always
Often
Seldom
Never
2. When appropriate, this student talks to selected peers (his/her friends) at school.
Always
Often
Seldom
Never
3. When called on by his/her teacher, this student answers verbally.
Always
Often
Seldom
Never
4. When appropriate, this student asks you (the teacher) questions.
Always
Often
Seldom
Never
5. When appropriate, this student speaks to most teachers or sta at school.
Always
Often
Seldom
Never
6. When appropriate, this student speaks in groups or in front of the class.
Always
Often
Seldom
Never
*7. When appropriate, this student participates nonverbally in class (i.e., points,
gestures, writes notes).
Always
Often
Seldom
Never
*8. How much does not talking interfere with school for this student?
Not at all
Slightly
Moderately Extremely
Scoring: Always = 3, Often = 2, Seldom = 1, Never = 0
* These items are not included in total score.
108
Selective Mutism Questionnaire (SMQ)
Please consider your childs 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
2. When appropriate, my child talks to selected peers (his/her friends) at school.
Always
Often
Seldom
Never
3. When my child is asked a question by his/her teacher, s/he answers.
Always
Often
Seldom
Never
4. When appropriate, my child asks his or her teacher questions.
Always
Often
Seldom
Never
5. When appropriate, my child speaks to most teachers or sta at school.
Always
Often
Seldom
Never
6. When appropriate, my child speaks in groups or in front of the class.
Always
Often
Seldom
Never
HOME/FAMILY
7. When appropriate, my child talks to family members living at home when
other people are present.
Always
Often
Seldom
Never
8. When appropriate, my child talks to family members while in unfamiliar
places.
Always
Often
Seldom
Never
9. When appropriate, my child talks to family members that dont live with
him/her (e.g., grandparent, cousin).
Always
Often
Seldom
Never
109
10. When appropriate, my child talks on the phone to his/her parents and
siblings.
Always
Often
Seldom
Never
11. When appropriate, my child speaks with family friends who are well-known
to him/her.
Always
Often
Seldom
Never
12. My child speaks to at least one babysitter.
Always
Often
Seldom
Never N/A
IN SOCIAL SITUATIONS (OUTSIDE OF SCHOOL)
13. When appropriate, my child speaks with other children who s/he doesnt know.
Always
Often
Seldom
Never
14. When appropriate, my child speaks with family friends who s/he doesnt
know.
Always
Often
Seldom
Never
15. When appropriate, my child speaks with his or her doctor and/or dentist.
Always
Often
Seldom
Never
16. When appropriate, my child speaks to store clerks and/or waiters.
Always
Often
Seldom
Never
17. When appropriate, my child talks when in clubs, teams, or organized activities outside of school.
Always
Often
Seldom
Never N/A
Interference/Distress*
18. How much does not talking interfere with school for your child?
Not at all
Slightly
Moderately Extremely
19. How much does not talking interfere with family relationships?
Not at all
Slightly
Moderately Extremely
20. How much does not talking interfere in social situations for your child?
Not at all
Slightly
Moderately Extremely
21. Overall, how much does not talking interfere with life for your child?
Not at all
Slightly
Moderately Extremely
110
22. Overall, how much does not talking bother your child?
Not at all
Slightly
Moderately Extremely
23. Overall, how much does your childs not talking bother you?
Not at all
Slightly
Moderately Extremely
Scoring: Always = 3; Often = 2; Seldom = 1; Never = 0
*These items are not included in total score and are for clinical purposes only.
Copyright 2008 R. Lindsey Bergman, Ph.D., Associate Clinical Professor,
UCLA Semel Institute for Neuroscience and Human Behavior
111
WEEKLY HOMEWORK FORM
CHILD:
THERAPIST:
T HERAPIST CONTACT INFO:
DATE ASSIGNED:
SESSION NUMBER:
ASSIGNMENT DESCRIPTION
Assignment #1:
Assignment #2:
Assignment #3:
Assignment #4:
COMMENTS:
Please contact the therapist if you need any instructions of clarification.
118
119
Small Prizes
Medium Prizes
PRIZE BRAINSTORMING FORM
Large Prizes
FEELINGS CHART
________________________________________________
________________________________________________
________________________________________________
________________________________________________
120
SITUATION RATING FORM
Instructions: Describe specific situations and how difficult they are. Some of these situations should NOT
include speaking and should be very easy situations so that this task is not overwhelming. Others should be
speaking situations.
EASY:
Situation:
Situation:
Situation:
MEDIUM:
Situ ation:
Situation:
Situation:
HARD:
Situation:
Situation:
Situation:
121
TALKING LADDER
Instructions: List situations to work on, with the easiest situations at the bottom of the ladder and the hardest
situations at the top.
122
PLAYDATE FORM
Date: _______________ Parent-Observer: _____________________________
Individuals Present: ____________________________________________________
Diculty rating:______ Setting: __________________________________________
Activities: _____________________________________________________
________________________________________________________________________
Parent Observations (record both verbal and nonverbal behavior):
123
CLASSMATE LIST
Instructions: Use this form to list the names of other children in class or program with your
child. If child has trouble with one gender more than the other, please list them separately.
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
Name:________________________M/F
124
CLASS CHART
Childs Name
Description
of Speech
Where Speech Quality of
Has Occurred Speech
Spoken
To Childs
Playdate? Parents?
125
EXPOSURE ASSIGNMENT FORM
CHILD: __________ PARENTS: _____________________________
Exposure with (circle one)
Teacher:______________Parent:________________Other:________________
Date assigned: ____/____/____ o Session Number: _______
ASSIGNMENT DESCRIPTION
a) Assignment: __________________________________________________________
________________________________________________________________
b) Reward expected: _____________________________________________________
______________________________________________________________________
************************************************************************
PARENT/TEACHER, PLEASE RECORD OUTCOME: COMPLETED
NOT COMPLETED
Please Describe Outcome of Assignment _____________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Therapist Notes on Assignment
c) Outcome of assignment: Not attemptednot possible
Not attemptedchild did not tolerate
Attempted not completed
Completed as assigned
Completed with modication
Child's feeling rating after exposure:
Check here _____ if child rating not obtained
Explain outcome: ________________________________________________________
______________________________________________________________________
_______________________________________________________________________
126
Other Individuals List
Use this form to list the children that your child knows from extracurricular activities outside
of school and other adults that your child interacts with outside of school. They can be listed
by name or type of person if adult (e.g., hairdresser, waiter).
CHILDREN:
ADULTS:
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
___________________________M/F
____________________________M/F
127
OTHER INDIVIDUALS CHART
Individuals
Name
128
Description of
Individual
Description of
Speech
Quality of
Speech
Normal
Spontaneous
Speech?
Exposure Ideas Form
CHILD: _______________ PARENTS: _______________TEACHER: _______________
Date assigned: _______/_______/_______
_______________________________________________
General Areas of Remaining Diculty:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Specic Ideas for Exposures:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
129
PROGRESS CHART:
ACCOMPLISHMENTS!
Instructions: Use the space below to record the childs progress, for example, categories might include classmates,
other kids, teachers, family members, or other adults.
Category (fill-in):
Category (fill-in):
Category (fill-in):
Category (fill-in):
Category (fill-in):
130
REMAINING GOALS WORKSHEET
GOAL
EXPOSURES
REWARD
131
_______________
for successful completion of the
Talking Program
_______________
This certicate is presented to
Certicate of
Achievement
