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Healthcare & Clinical

Family Therapy Intake and Concerns Assessment

Gathers a new family therapy client's presenting concerns, family structure, history, and goals before the first session, with an AI follow-up that explores the core relational conflict in the client's own words. Built for family and marriage therapists to speed up intake and arrive at session one with real context.

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設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全15問・約8分
Q01
メッセージ

Welcome, and thank you for taking this step. Before your first session, we'd like to understand a bit about your family and what brings you in. This takes about 6-8 minutes, and everything you share is confidential and only used by your therapist.

Q02
自由回答（短文）必須

Who is completing this intake form (your name and relationship to the family, e.g. 'parent', 'adult child')?

Q03
選択式必須

Who will be attending family therapy sessions?

  • Both/all parents or guardians
  • One parent or guardian
  • Children or teens in the home
  • Siblings
  • Extended family (grandparents, etc.)
  • Partner/spouse
Q04
自由回答（長文）必須

In your own words, what is the main reason your family is seeking therapy right now?

Q05
選択式必須

Which areas is your family currently struggling with?

  • Communication and conflict
  • Parenting disagreements
  • A recent major change (divorce, move, loss, illness)
  • A child or teen's behavior or mental health
  • Substance use in the family
  • Financial stress
  • Blended family or step-family adjustment
  • Trust or infidelity
Q06
オピニオンスケール必須

In the last 30 days, how often has conflict in your family disrupted daily life (meals, sleep, work, or school)?

スケール: 0 – 10
最小:Never disrupted最大:Disrupted constantly
Q07
マトリクス必須

How would you rate the current state of these areas in your family?

5行 × 5列
  • Communication between family members
  • Trust and honesty
  • Ability to resolve disagreements
  • Emotional closeness
  • Consistency in parenting or household rules
列: Very poor · Poor · Fair · Good · Very good
Q08
選択式必須

Has your family received counseling or therapy together before?

  • Yes, and it helped
  • Yes, but it didn't help much
  • No, this is our first time
Q09
選択式必須

Are there any safety concerns we should know about before your first session (e.g. domestic violence, self-harm risk, active substance abuse)?

  • Physical violence or fear of harm
  • Thoughts of self-harm or suicide by a family member
  • Active substance abuse affecting safety
  • Child safety concern
Q10
AIインタビュー

Gently explore the core relational conflict the respondent named as the main reason for seeking therapy: ask for a recent specific example of when it happened, who was involved, what each person did or said, and how it typically ends. If they flagged any safety concern, prioritize understanding current safety and whether they need immediate support rather than probing the conflict further, and note this clearly for the therapist. If their answer is vague or minimizing, ask what a hard week for this family actually looks like.

Q11
自由回答（長文）

What would you consider a meaningful sign of progress after a few months of family therapy?

Q12
自由回答（短文）

Is there anything about your family's culture, faith, or background you'd like your therapist to understand from the start?

Q13
プルダウン

What is the approximate age range of the youngest child involved in therapy, if any?

  • No children involved
  • Under 5
  • 5-9
  • 10-13
  • 14-17
  • 18 or older
Q14
選択式

Household income range (optional, helps us discuss fee options if relevant)

  • Under $30,000
  • $30,000-$59,999
  • $60,000-$99,999
  • $100,000 or more
  • Prefer not to say
Q15
メッセージ

Thank you for sharing this with us — it takes courage to reach out. Your therapist will review these answers before your first session so you can spend that time talking about what matters most, not filling out forms.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Captures presenting concerns, family structure, history, and goals in the client's own words before session one, so therapists arrive with real context
  • Includes an AI follow-up interview that gently explores the core relational conflict the client named as their main reason for seeking therapy, going beyond a static field
  • Covers practical intake needs therapists need before a first session — who's attending, prior counseling history, safety concerns, and a matrix rating current family functioning across key areas
  • Closes with a warm, transparent chat message setting expectations for how the shared information will be used in the first session

Jotform

Family Therapy Intake Form Template

A ready-to-field static intake form builder template covering standard family therapy intake fields like contact info and presenting concerns. It's a form-builder product, so customization is flexible, but every respondent sees the same fixed question set. No mechanism exists to probe deeper into a stated concern.

優れている点

  • Fielding-ready template usable immediately
  • Familiar drag-and-drop form builder for easy customization
  • Likely supports file uploads and e-signature for intake paperwork

物足りない点

  • Static form with no adaptive follow-up to explore the client's stated concerns further
  • No AI-driven quality scoring of responses
  • No voice interview option for clients who prefer speaking over typing

Typeform

Family Therapy Intake Form Template

A polished, conversational one-question-at-a-time intake template well-suited to therapy's sensitive tone. It relies on branching logic rather than genuine AI-driven follow-up, so it can route respondents down predefined paths but cannot dynamically generate a new question based on what a client actually writes.

優れている点

  • Clean, conversational UI that suits a sensitive intake context
  • Logic-based branching to skip/show questions based on prior answers
  • Strong mobile-friendly design and completion experience

物足りない点

  • No adaptive AI follow-up that responds to the client's own words about their core conflict
  • No automated per-response quality scoring or auto-generated clinical-context reports
  • No optional voice AI interview mode for clients who prefer talking

よくあるご質問

「Family Therapy Intake and Concerns Assessment」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が15問含まれており、最初の設問は次のとおりです：「Welcome, and thank you for taking this step. Before your first session, we'd like to understand a bit about your family…」・「Who is completing this intake form (your name and relationship to the family, e.g. 'parent', 'adult child')?」・「Who will be attending family therapy sessions?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、15問を約8分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

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