Please click on the corresponding tab to find all of the relevant information and forms to fill out before your upcoming appointment.
To complete before your initial appointment:
Then, fill out the following forms:
SM School Evaluation Form (to be completed by child’s teacher)
**For Intensive Programs Only**
You will be emailed the following forms to complete as well:
Sensory Profile 2
Recommended Reading to prepare for your initial visit:
Parents, teachers and children/teens are encouraged to update the SMart Center Team on a regular basis! This information helps us understand and keep up with the treatment process between visits! So, keep those updates coming!
Please update our center on your progress by completing the following forms before your next appointment!
(Each form needs to be filled out at least 3 days before each follow-up consultation)
SM School Evaluation Form (To be filled out by your child’s teacher)
**For children/teens 10 years+ only**:
Older Child/Teen Follow-Up Form (Patient is to fill this out themselves)
Front Desk Call Center: 215-887-5748 Direct Patient Line: 215-886-6090 Fax: 215-827-5722
Have an upcoming WebEx follow-up consultation?
Please click here to read over important information to prepare for your appointment.
The following forms need to be completed and returned to the SMart Center 48 hours prior to the scheduled observation or consultation.
Forms can be sent via email to firstname.lastname@example.org, faxed to 215-827-5722, or mailed to SMart Center, 505 N. Old York Rd., Lower Level, Jenkintown, PA 19046.
School Evaluation Form
For teacher to complete online (The teacher can create whatever username and password they wish as a new user).
For school representative & student’s parent to complete.
Brief SMCDQ – School Version
For student’s parent to complete online.
A professional consult is a non-patient consultation that is ideal for parents, school personnel or treatment professionals who are interested in a Question/Answer consultation.
IMPORTANT: There is no clinician-patient relationship established in a professional consultation format.
If you have scheduled a professional consultation, please complete the following forms before your appointment:
Selective Mutism Comprehensive Diagnostic Questionnaire
This SMCDQ allows our clinical team to get a overview of your child/student. We ask the child’s parents to complete this form or the child’s school staff to complete it the best of their ability.
SM School Evaluation Form
This questionnaire should be completed by the child’s school personnel.
Waiver of Liability (Links below, differ by clinician)
The Waiver of Liability confirms to the SMart Center that you are aware that the professional consultation is an informational session only and is NOT meant to serve as an evaluation of a child. This form should be completed by BOTH the child’s parents and a school staff representative if both the child’s parents and child’s school team are attending this consultation. Please find the correct corresponding waiver below.
Professional Consultation with Dr. Shipon-Blum Waiver
Professional Consultation with Jennifer Waiver