SELF-HELP SCREENING TEST
Do you have symptoms of Selective Mutism?

The following questions can be used to help you recognize the symptoms of Selective Mutism.
This form is not meant to replace consultation with a trained mental health professional.
An accurate diagnosis can only be made through a clinical evaluation.
Please print out this form and give to your physician to discuss the results and any concerns. 

Answer questions for your child who may be experiencing these symptoms:
 Does your child have an ongoing fear of social situations involving unfamiliar settings?

 Does your child have a persistent and unreasonable fear of speaking in the classroom, to other kids or adults including school
settings, restaurants or a store?

 Does the anxiety interfere with your child’s daily life?

 Does the child appear anxious when interacting with peers?

 When the child is expected to speak does he/she react by having a blank expression on his/her face?

 Does the child cling to parents or hide in a corner of the room when an outsider visits the home?

 Does the child smile in photos taken by professional photography (other than snapshots taken at home)?

 Does the child worry excessively about speaking in public?

 Does the child worry excessively about being called upon by the teacher in class to verbally respond?

 Has the child suffered in classroom performance due to non-verbalization? 

 Is the child reluctant to go to school or avoid age appropriate social activities? 

 Does the child experience headaches or stomachaches about attending school?

 Does the child speak at home in a normal voice but does not verbalize in public?

 Has the non-verbalization in school or public setting been for more than one month?

Reference Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR 2000), 4th edition, Washington DC, American Psychiatric
Association 2000.

Disclaimer: This fact sheet is provided as an educational tool for self-help screening only. The information is not intended as
professional advice or diagnosis. We strongly recommend that you be evaluated by a mental health professional for an accurate
diagnosis. The Selective Mutism Foundation, Inc may not be held liable in any way.