Assessment Forms for Consultations at the SMart Center

Assessment Forms for Consultations at the SMart Center Please click on the consultation you have chosen:

If you are not sure which format you would like, Please call our staff OR, you can discuss with Dr. Shipon-Blum at your upcoming consultation.
** For families without an appointment but on the REVOLVING WAIT LIST ---> GO

*Comprehensive Initial Consultation
Per-Service Consultation
Ask The Doc Consultation

Have questions about format choices OR other SMart Center policies/procedures?

Please note our FEE POLICIES

For questions about assessment forms, please contact us.
Our staff is happy to help!
By email: smartcenter06@yahoo.com
By phone (For those with scheduled appointments only!) 215-886-6090.

REVOLVING WAIT LIST

For Comprehensive and Per Serive consultations with Dr. Shipon-Blum, please FILL out the following forms. Once filled out, please EMAIL or call: (215-886-6090) our staff to advise them that you have completed forms and ready for your consultation. We will then CALL YOU when an appt slot opens up. FEEL free to contact our office (email or phone) to ask about status.

You will need to fill out the following assessment forms prior to your consultation.

*SM-CDQ ‘Selective Mutism-Comprehensive Diagnostic Questionnaire
*SM-School Evaluation Form (c) (Teacher form)
*Symptom Inventory (Parent/Teacher)
*Social Phobia Anxiety Index
*Sensory Profile

*** Please be sure to scroll down entire page to access assessment forms

NOTE: For questions on assessment forms, need information mailed or faxed,
please call our Direct Patient line at: 215-886-6090

1. SM-CDQ (c) (c) Questionnaire:

**We must receive the SM-CDQ ASAP or at least 3 days PRIOR to your consultation.
**The questionnaire is long and does take time to fill out. The estimated time to fill out the questionnaire will be 60-120 minutes. The information received will allow for a detailed picture of your child which will help in the development of a successful treatment & school accommodation/intervention plan.

**Please be as elaborate and as detailed as possible with your answers on the questionnaire. The more information presented, the more it will help in the evaluation and assessment of your child!!!

ACCESS SM-CDQ and submit online: **Preferred method of submission
Access the SM-CDQ ©, FILL out and Submit ONLINE!!
http://smgcan.org/surveys/compquest_instantmember.html

As you progress thru the SM-CDQ, click “MODIFY.” to save your information. We will automatically receive your information. You do not need to fill out the entire form in one sitting. Choose a password and username that you will remember. You can complete at another time. We recommend your child's first (password) and last name (username). Since this is a confidential form, no one will have access to this password/username other than YOU. However, by using your child's name, this will prevent you from LOSING your password/username.

If you do not use your child's first/last name, WRITE DOWN and remember your password/username. We do not have access to the password/username you choose.

You can contact us to be sure we received your SM-CDQ. Please email: smartcenter@selectivemutism.org Subject: SM-CDQ

We will look up your information and promptly get back to you! We do suggest that you SAVE a final version of the SM-CDQ on your computer and/or print for your records. There have been rare occasions that we did not receive the SM-CDQ and having a backup copy will save you the time of having to refill out the information!
ACCESS SM-CDQ via WORD or PDF file. Then PRINT, Complete and Mail or FAX.
Some families would rather print the questionnaire, write in their responses, and then mail or FAX their completed questionnaire. That is fine. Please access by SM-CDQ (Word Document) or SM-CDQ (PDF)

You can mail the questionnaire or FAX to: 215-827-5722.
*This fax is only used by our office staff. You information is therefore confidential and not seen by anyone outside of our office.

2. SM- School Evaluation Form©:

We must receive the SM School EVAL form at least 3 days PRIOR to your consultation. If you would like to WAIT on this form until you have a scheduled appt date, that is fine. Just be sure to SEND prior to your consultation so that Dr. E can evaluate!

Access the SM-SEF by going to: School Evaluation Form

This will need to be printed, then filled out by the school teacher who has the most contact with your child. For the majority, it is the classroom teacher. If you believe there are multiple teachers who can give input on your child's social/communication/academic functioning, you are welcome to submit more than one form.

Teachers can fax the form back, mail the form back or give to YOU to fax back (215-827-5722). Note: *The fax number and address are on the form.

**This form is crucial in the evaluation/assessment process. An understanding of your child’s ability to communicate, interact and perform school work will help us with our overall treatment approach/plan.

3. Symptom Inventory:

The Symptom Inventory screens for over 13 psychiatric disorders and helps our clinicians address any co-existing difficulties your child may have.

ACCESS Symptom Inventory ONLINE, then PRINT, Complete and Mail/FAX.

Symptom Inventory

§ You will find two versions - a parent version and a teacher version

§ Please try and have this year’s teacher fill out the system inventory. If that is not possible, then have last year’s teacher or another teacher (s) who knows your child in the ‘school setting.’ Understanding your child’s behaviors within the school are important in determining necessary accommodations/interventions.

§ You can mail the symptom inventory or FAX to: 215-827-5722.
The forms do not have to arrive at the same time if you and the teacher send independently.

4. SPAI-C (Social Phobia Anxiety Inventory)

ACCESS SPAI-C and submit online!
The (SPAI-C) has a parent and child version:

**Parent (mother or father) fills out a form ABOUT the child.
Please go to: http://smgcan.org/surveys/spaicpe_instantmember.html

**Adolescent or Child > 9 yrs old, fills out a form about themself.
Please go to: http://smgcan.org/surveys/spaicce_instantmember.html

*If your child does not want to fill out this form, it is not mandatory, however, it is important that your child become pro-active in his/her treatment process, so we do encourage your child's help in this area

Note: If you would rather PRINT and fill out by hand or you do not feel comfortable with child filling out form online, please go to link, and then PRINT. Handwrite answers then either mail or FAX to 215-827-5722.

*** You will need to add a password and username for this form.
Please use your child’s first name. All lower case letters. Ie,: sophia

5. Sensory Profile:

Children with SM tend to have ‘sensory issues’ in addition to their SM. This profile will help screen for various sensory sensitivities.

Access the Sensory Profile and submit online!
The Sensory Profile has a parent and child version:

**Parent (mother or father) fills out a form ABOUT the child.
Please go to: http://smgcan.org/surveys/caregiver_instantmember.html

**Adolescent or child > 9 yrs old, we encourage the child to fill out form about themselves.
Please go to: http://smgcan.org/surveys/adult_instantmember.html
*If your child does not want to fill out this form, it is not mandatory, however, it is important that your child become pro-active in his/her treatment process, so we do encourage your child's help in this area.

Consultation checklist for Per Service Consultation, Comprehensive Initial Consultation, Home/School Treatment Plans:
**We must receive the assessment forms ASAP (to allow for sudden appointment slot openings and moving your appt up!) OR at least 3 days PRIOR to your consultation if you do not want to change your presently scheduled appointment.
*** We also suggest making copies of each of your assessment forms and bringing with you the DAY of your appointment
OR, contact us (smartcenter@selectivemutism.org to verify that we have received each of your assessment forms)

____ SM CDQ © (questionnaire) (submitted online (preferred), mailed or faxed.

Please bring with you the DAY of your consult or mailed PRIOR to your consult:

____ VIDEO (DVD preferred) **Required for ALL teleconferences. Optional for in-person visits however, your clinician may request this after your initial in-person consultation
* Please be sure to keep a copy of the video that is provided since we do not return the videos.

____ $100 Deposit required within ONE week of scheduling appointment. Deposit is 100% refundable if appointment is cancelled prior to two weeks of appointment. Deposit is forfeited if cancelled within two weeks of appointment day. NO exceptions can be made. Rescheduling of an appointment is permitted.
Balance of Payment via check/money order required at time of in-person consultation
Balance of Payment via check/money order required at least one week prior to scheduled Teleconference date.

Please mail to:
SMart Center
505 Old York Road
Lower Level
Jenkintown, PA 19046
Attention: New consultation-confidential

FAX: 215-827-5722 (confidential to our staff only)

Please call us, or e-mail the SMART-Center if you have ANY questions. We are here for you and promise to help you through this process.

Our professional staff members as well as our administrative staff have a personal interest in SM and can relate to your concerns and desire to help your child.

In addition, Since Dr. E has a daughter who had Selective Mutism, she has been where you are and completely understand your feelings. Read Dr. Shipon-Blum's story

The STAFF at the SMART-Center

Phone: 215-887-5748 24/7
Direct Patient Line: 215-886-6090 (For our established patients or patients with scheduled appointments) M-F 9 am- 4 pm
Fax: 215-827-5722
E-mail: smartcenter06@yahoo.com

----------------------------------------------------------------------------------------------------------------------------------------------------------

ASK

Ask the Doc Consultation
One hour Question/Answer Session
Teleconference only.

You will need to fill out the following forms prior to your consultation.
We must receive the SM-CDQ at least 3 days PRIOR to your consultation.
*Brief-SM-CDQ ‘Selective Mutism-Comprehensive Diagnostic Questionnaire
*Waiver of Liability*** Please be sure to scroll down entire page to access assessment forms

NOTE: For questions on assessment forms, need information mailed or faxed,
please call our Direct Patient line at: 215-886-6090

The Brief SM-CDQ is a very short questionnaire that will help the doctor with a brief overview of your child. This is for informational purposes to help the doctor prepare for your ASK THE DOC consultation and not meant to be an evaluation tool for treatment specific to your child.
Brief SM-CDQ (Word Document)

The waiver of liability informs you and confirms to us that you are aware that the ASK THE DOC consultation is for informational purposes and not meant to replace a complete evaluation of your child.
Waiver of Liability (Word Document)

ASK THE DOC consultation checklist
**We must receive the SM-CDQ at least 3 days PRIOR to your consultation.

____ Brief SM-CDQ © (questionnaire) (WORD doc you can access online, PRINT, Mail/FAX

____       Waiver of Liability (Word Doc that you can access online, PRINT, Mail/FAX

____       FULL payment via check/money order required within ONE week of scheduling appointment. FULL refund is given to patient if cancelled Prior to two weeks of appointment date.
              Forfeit payment if cancelled within two weeks of scheduled consultation.

Please mail to:
SMart Center
505 Old York Rd
Lower Level
Jenkintown, PA 19046
Attention: ASKtheDOC/DATE of consultation.

FAX: 215-827-5722 (confidential to our staff only)

Please call us, or e-mail the SMART-Center if you have ANY questions. We are here for you and promise to help you through this process.

In addition, Since Dr. E has a daughter who had Selective Mutism, she has been where you are and completely understand your feelings.

The STAFF at the SMART-Center

Phone: 215-887-5748
Direct Patient Line: 215-886-6090 (For our established patients or patients with scheduled appointments) M-F 9 am- 4 pm
Fax: 215-827-5722
E-mail: smartcenter06@yahoo.com

Comprehensive Consultation

You will need to fill out the following assessment forms at least 3 days prior to your consultation.

Note: 1. We suggest filling out and submitting assessment forms ASAP so that if an appt slot opens sooner then your presently scheduled appointment, you are ready to go! 2. Teachers can fax, email or mail in their forms

*SM-CDQ ‘Selective Mutism-Comprehensive Diagnostic Questionnaire (Parent/caregiver only)
*SM-School Evaluation Form (c) (Teacher Form)
*Symptom Inventory (Parent and Teacher version)
*Social Phobia Anxiety Index (Parent/caregiver; older child version)
*Sensory Profile (Parent/caregiver; older child version)

*** Please be sure to scroll down entire page to access assessment forms

After completion of above forms, please use the checklist provided for YOUR confirmation that you have completed all necessary forms.

NOTE: For questions on assessment forms, need information mailed or faxed,
please call our Direct Patient line at: 215-886-6090

1. SM-CDQ (c) (c) Questionnaire:

ACCESS SM-CDQ and submit online: **Preferred method of submission
Access the SM-CDQ ©, FILL out and Submit ONLINE!!
http://smgcan.org/surveys/compquest_instantmember.html

As you progress thru the SM-CDQ, click “MODIFY.” to save your information. We will automatically receive your information. You do not need to fill out the entire form in one sitting. Choose a password and username that you will remember. You can complete at another time. We recommend your child's first (password) and last name (username). Since this is a confidential form, no one will have access to this password/username other than YOU. However, by using your child's name, this will prevent you from LOSING your password/username.

If you do not use your child's first/last name, WRITE DOWN and remember your password/username. We do not have access to the password/username you choose.

You can contact us to be sure we received your SM-CDQ. Please email: smartcenter@selectivemutism.org Subject: SM-CDQ

We will look up your information and promptly get back to you! We do suggest that you SAVE a final version of the SM-CDQ on your computer and/or print for your records. There have been rare occasions that we did not receive the SM-CDQ and having a backup copy will save you the time of having to refill out the information!
ACCESS SM-CDQ via WORD or PDF file. Then PRINT, Complete and Mail or FAX.
Some families would rather print the questionnaire, write in their responses, and then mail or FAX their completed questionnaire. That is fine. Please access by SM-CDQ or SM-CDQ

You can mail the questionnaire or FAX to: 215-827-5722.
*This fax is only used by our office staff. You information is therefore confidential and not seen by anyone outside of our office.

2. SM- School Evaluation Form©:

We must receive the SM School EVAL form ASAP or at least 3 days PRIOR to your consultation.

Access the SM-SEF by going to: /cms/school_evaluation_form.aspx

3. Symptom Inventory:

**We must receive the Symptom Inventory ASAP or at least 3 days PRIOR to your consultation.

The Symptom Inventory screens for over 13 psychiatric disorders and helps our clinicians address any co-existing difficulties your child may have.

ACCESS Symptom Inventory ONLINE, then PRINT, Complete and Mail/FAX.

/cms/symptom_inventory.aspx

§ You will find two versions - a parent version and a teacher version

§ You can mail the symptom inventory or FAX to: 215-827-5722.
The forms do not have to arrive at the same time if you and the teacher send independently.

4. SPAI-C (Social Phobia Anxiety Inventory)

**We must receive the SPAI-C ASAP or at least 3 days PRIOR to your consultation.

5. Sensory Profile:

**We must receive the Sensory Profile ASAP or at least 3 days PRIOR to your consultation.

Children with SM tend to have ‘sensory issues’ in addition to their SM. This profile will help screen for various sensory sensitivities.

Access the Sensory Profile and submit online!
The Sensory Profile has a parent and child version:

**Parent (mother or father) fills out a form ABOUT the child.
Please go to: http://smgcan.org/surveys/caregiver_instantmember.html

In order for your treatment professional to KNOW your child better, we encourage you to send us the
most RECENT and/or most RELEVANT copies of:

Your child’s recent school report cards ** if you believe this will add to a better understanding of your child
Academic testing reports (IE, IQ testing, Achievement tests, etc.)
Psychological testing, Speech and Language testing
Recent Physical Examination reports from child’s personal physician. ** if you believe this will add to a better understanding of your child
For Telephone consults (required) and In-Person consultations (optional) please submit a 10-30 minute DVD of your child speaking and interacting with you at home or somewhere comfortable. If you can get a video of your child when mute and anxious, such as at school or during another social function, please submit that as well!!****
* Please be sure to keep a copy of the DVD since we not return tapes.

Consultation checklist for Per Service Consultation, Comprehensive Initial Consultation.

**We must receive the assessment forms at least 3 days PRIOR to your scheduled consultation.
Ideally, submit forms ASAP in case of sudden appointment slot openings and moving your appt up!)

We prefer that any online forms are submitted online which allow forms to go directly into our database.
However, ALL Forms can be printed, filled out and submitted via EMAIL, FAX or MAIL. OUR email and fax line is confidential.

*** Make copies of each of your assessment forms and bringing with you the DAY of your appointment.

You can contact us at: smartcenter06@yahoo.com to confirm the arrival of your assessment forms.

____ SM CDQ © (questionnaire)

____       SM-Teacher Evaluation Form © (Teacher version)

____       System inventories (Parent and teacher versions)

____       SPAI-C © (Parent and older child/teen version)

____       Sensory Profiles (Paent and older child/teen version

Please bring with you the DAY of your consult or mailed PRIOR to your consult:

____        ** Optional. VIDEO (DVD or online link preferred) **Required for ALL teleconferences. Optional for in-person visits however, your clinician may request this after your initial in-person consultation
                    * Please be sure to keep a copy of the video that is provided since we do not return.

____        ** Optional. Relevant and RECENT Report cards, relevant educational testing reports and/or psychological testing reports

Upon initial scheduling:

____         $100 Deposit required within ONE week of scheduling appointment. Deposit is 100% refundable if appointment is cancelled prior to two weeks of appointment. Deposit is forfeited if cancelled within two weeks of appointment day. NO exceptions can be made. Rescheduling of an appointment is permitted.
Balance of Payment  via check/money order required at time of in-person consultation
Balance of Payment via check/money order required at least one week prior to scheduled Teleconference date.

Please mail to:
SMart Center
505 Old York Road
Lower Level
Jenkintown, PA 19046
Attention: New consultation-confidential

FAX: 215-827-5722 (confidential to our staff only)

Please call us, or e-mail the SMART-Center if you have ANY questions. We are here for you and promise to help you through this process.

Our professional staff members as well as our administrative staff have a personal interest in SM and can relate to your concerns and desire to help your child.
We also encourage you to take advantage of SMG~CAN member benefits.

In addition, Since Dr. E has a daughter who had Selective Mutism, she has been where you are and completely understand your feelings.

The STAFF at the SMART-Center

Phone: 215-887-5748 24/7
Direct Patient Line: 215-886-6090 (For our established patients or patients with scheduled appointments) M-F 9 am- 4 pm
Fax: 215-827-5722
E-mail: smartcenter06@yahoo.com

----------------------------------------------------------------------------------------------------------------------------------------------------------

ASK

imp

Per Service Consultation

1. SM-CDQ (c) (c) Questionnaire:

ACCESS SM-CDQ and submit online: **Preferred method of submission
Access the SM-CDQ ©, FILL out and Submit ONLINE!!
http://smgcan.org/surveys/compquest_instantmember.html

As you progress thru the SM-CDQ, click “MODIFY.” to save your information. We will automatically receive your information. You do not need to fill out the entire form in one sitting. Choose a password and username that you will remember. You can complete at another time. We recommend your child's first (password) and last name (username). Since this is a confidential form, no one will have access to this password/username other than YOU. However, by using your child's name, this will prevent you from LOSING your password/username.

If you do not use your child's first/last name, WRITE DOWN and remember your password/username. We do not have access to the password/username you choose.

You can contact us to be sure we received your SM-CDQ. Please email: smartcenter@selectivemutism.org Subject: SM-CDQ

We will look up your information and promptly get back to you! We do suggest that you SAVE a final version of the SM-CDQ on your computer and/or print for your records. There have been rare occasions that we did not receive the SM-CDQ and having a backup copy will save you the time of having to refill out the information!
ACCESS SM-CDQ via WORD or PDF file. Then PRINT, Complete and Mail or FAX.
Some families would rather print the questionnaire, write in their responses, and then mail or FAX their completed questionnaire. That is fine. Please access by SM-CDQ or SM-CDQ

You can mail the questionnaire or FAX to: 215-827-5722.
*This fax is only used by our office staff. You information is therefore confidential and not seen by anyone outside of our office.

2. SM- School Evaluation Form©:

We must receive the SM School EVAL form ASAP or at least 3 days PRIOR to your consultation.

Access the SM-SEF by going to: /cms/school_evaluation_form.aspx

ACCESS Symptom Inventory ONLINE, then PRINT, Complete and Mail/FAX.

/cms/symptom_inventory.aspx

§ You will find two versions - a parent version and a teacher version

§ You can mail the symptom inventory or FAX to: 215-827-5722.
The forms do not have to arrive at the same time if you and the teacher send independently.

4. SPAI-C (Social Phobia Anxiety Inventory)

**We must receive the SPAI-C ASAP or at least 3 days PRIOR to your consultation.

**Parent (mother or father) fills out a form ABOUT the child.
Please go to: http://smgcan.org/surveys/caregiver_instantmember.html

OPTIONAL: ** If you believe past records, such as academic, psychological or Speech/Language testing reports or school report cards will help Dr. E gain a great understanding of your child, please submit the MOST recent evaluations via fax or bring with you to your appt.

** DVD of your child:
For Telephone consults (required) and In-Person consultations (optional) please submit a 10-30 minute DVD of your child speaking and interacting with you at home or somewhere comfortable. If you can get a video of your child when mute and anxious, such as at school or during another social function, please submit that as well!!****
* Please be sure to keep a copy of the tape that is sent since we not return DVD's.

Consultation checklist for Per Service Consultation, Comprehensive Initial Consultation, Home/School Treatment Plans:
**We must receive the assessment forms ASAP (to allow for sudden appointment slot openings and moving your appt up!) OR at least 3 days PRIOR to your consultation if you do not want to change your presently scheduled appointment. *** We also suggest making copies of each of your assessment forms and bringing with you the DAY of your appointment
OR, contact us (smartcenter@selectivemutism.org to verify that we have received each of your assessment forms)

____       SM-Teacher Evaluation Form © (Printed and given to teacher to either mail/fax OR given to you to mail/fax

____       System inventories ( parent and teacher versions) (Printed and mailed/faxed)

____       SPAI-C © (Parent and older child version; submitted online or printed and mailed/faxed)

____       Sensory Profiles (Parent and older child version; submitted online or printed and mailed/faxed)

Please bring with you the DAY of your consult or mailed PRIOR to your consult:

____        ** Optional. VIDEO (DVD or online link preferred) **Required for ALL teleconferences. Optional for in-person visits however, your clinician may request this after your initial in-person consultation
                    * Please be sure to keep a copy of the video that is provided since we do not return.

Please mail to:
SMart Center
505 Old York Road
Lower Level
Jenkintown, PA 19046
Attention: New consultation-confidential

FAX: 215-827-5722 (confidential to our staff only)

Please call us, or e-mail the SMART-Center if you have ANY questions. We are here for you and promise to help you through this process.

In addition, Since Dr. E has a daughter who had Selective Mutism, she has been where you are and completely understand your feelings.

The STAFF at the SMART-Center

Phone: 215-887-5748 24/7
Direct Patient Line: 215-886-6090 (For our established patients or patients with scheduled appointments) M-F 9 am- 4 pm
Fax: 215-827-5722
E-mail: smartcenter06@yahoo.com

Assessment Forms for Consultations at the SMart Center

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