すべてのテンプレート
Healthcare & Clinical

Mental Health Care Access & Provider Fit Survey

Assesses barriers to mental health care, provider-patient fit, telehealth preferences, wait times, and affordability. Designed for health systems, insurers, and researchers seeking to identify actionable improvements in mental health service delivery.

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31問・約13分
Q01
メッセージ

Welcome and thank you for participating in this survey about mental health care access and experiences. This survey is voluntary. You may skip any question or stop at any time. There are no right or wrong answers—we are interested in your honest opinions and experiences. Your responses are confidential and will be reported only in aggregate. No personally identifying information will be shared. The results will be used to improve mental health services and provider matching. The survey takes approximately 8–10 minutes to complete.

Q02
選択式

In the last 12 months, did you try to get mental health care?

  • Yes, I saw a provider
  • Yes, I tried but did not get an appointment
  • No
  • Prefer not to say
Q03
オピニオンスケール

How well did your most recent provider's expertise match your needs?

スケール: 1 – 7
最小:Not at all well最大:Extremely well
Q04
プルダウン

How long did you wait for your most recent new-patient mental health appointment?

  • Same week
  • 1–2 weeks
  • 3–4 weeks
  • 1–2 months
  • 3+ months
  • I never got an appointment
Q05
選択式

In the last 12 months, did you use telehealth (video or phone) for mental health care?

  • Yes, video visits
  • Yes, phone calls
  • Yes, both
  • No
Q06
選択式

How do you usually pay for mental health care?

  • Employer-sponsored insurance
  • Individual/Marketplace plan
  • Medicaid
  • Medicare
  • Student plan
  • Military/VA (e.g., TRICARE)
  • Uninsured/self-pay
  • Other
  • Prefer not to say
Q07
選択式

What, if anything, might keep you from seeking mental health care in the next 6 months? Select all that apply.

  • I feel fine / no need
  • Prefer self-help or informal support
  • Privacy or stigma concerns
  • Cost or coverage
  • Unsure how to get started
  • Scheduling or transportation
  • Past negative experience
  • Don't trust providers
  • Other
  • Nothing is likely to prevent me
Q08
ランク付け

Please rank the following from most to least important when choosing a mental health provider.

  1. Expertise that matches my concerns
  2. Appointments available soon
  3. Insurance accepted / low out-of-pocket cost
  4. Good communication style / rapport
  5. Cultural or language match
  6. Telehealth availability
  7. Location / convenience
ドラッグして順位を付ける
Q09
自由回答(長文)

Based on your responses in this survey, please share any additional thoughts or feelings about your experience getting or receiving mental health care.

Q10
プルダウン

What is your age?

  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65+
  • Prefer not to say
Q11
メッセージ

Thank you for completing this survey. Your responses are confidential and will be used to help improve mental health care access and provider matching. If you are currently experiencing a mental health crisis, please contact the 988 Suicide & Crisis Lifeline by calling or texting 988.

Q12
選択式

Which type(s) of mental health provider did you see in the last 12 months? Select all that apply.

  • Psychiatrist (MD/DO)
  • Psychologist (PhD/PsyD)
  • Therapist/Counselor (e.g., LCSW, LMFT, LPC)
  • Primary care clinician
  • Psychiatric nurse practitioner
  • Group therapy program
  • Other
  • Not applicable—I did not see a provider
Q13
オピニオンスケール

My most recent provider listened carefully to my concerns.

スケール: 1 – 7
最小:Strongly disagree最大:Strongly agree
Q14
選択式

Which of the following, if any, made it difficult for you to get a mental health appointment? Select all that apply.

  • No providers taking new patients
  • Waitlist too long
  • Cost too high or insurance not accepted
  • Couldn't find a provider who fit my needs
  • Available times didn't fit my schedule
  • Transportation or distance
  • Uncomfortable seeking care
  • Technology barriers
  • Other
  • None of the above
Q15
オピニオンスケール

Compared with in-person visits, telehealth was more convenient.

スケール: 1 – 7
最小:Strongly disagree最大:Strongly agree
Q16
プルダウン

Approximately how much did you pay out of pocket for your most recent mental health visit?

  • $0 (fully covered)
  • $1–$25
  • $26–$50
  • $51–$100
  • $101–$200
  • More than $200
  • Don't know / Prefer not to say
Q17
オピニオンスケール

How likely are you to seek mental health care in the next 6 months?

スケール: 1 – 7
最小:Very unlikely最大:Very likely
Q18
AIインタビュー

We'd like to learn a bit more about your mental health care experience. An AI moderator will ask a couple of brief follow-up questions.

Q19
選択式

Which best describes your gender?

  • Woman
  • Man
  • Non-binary or gender diverse
  • Prefer not to say
Q20
プルダウン

Approximately how many mental health appointments did you have in the last 12 months?

  • 0
  • 1–3
  • 4–6
  • 7–12
  • 13–24
  • 25 or more
Q21
オピニオンスケール

My most recent provider explained treatment options clearly.

スケール: 1 – 7
最小:Strongly disagree最大:Strongly agree
Q22
オピニオンスケール

Compared with in-person visits, the quality of care via telehealth was just as good.

スケール: 1 – 7
最小:Strongly disagree最大:Strongly agree
Q23
オピニオンスケール

Overall, my mental health care costs were affordable.

スケール: 1 – 7
最小:Strongly disagree最大:Strongly agree
Q24
プルダウン

Where do you currently live?

  • United States
  • Canada
  • United Kingdom
  • Australia
  • European Union
  • Other
Q25
オピニオンスケール

My most recent provider made me feel comfortable and respected.

スケール: 1 – 7
最小:Strongly disagree最大:Strongly agree
Q26
オピニオンスケール

Compared with in-person visits, I felt just as comfortable being open and honest during telehealth sessions.

スケール: 1 – 7
最小:Strongly disagree最大:Strongly agree
Q27
プルダウン

What is the highest level of education you have completed?

  • Less than high school
  • High school or GED
  • Some college / Associate degree
  • Bachelor's degree
  • Graduate or professional degree
  • Prefer not to say
Q28
選択式

In the last 12 months, did you switch mental health providers?

  • Yes
  • No
  • Not applicable
Q29
プルダウン

What is your current employment status?

  • Full-time
  • Part-time
  • Self-employed
  • Student
  • Unemployed
  • Homemaker
  • Retired
  • Unable to work
  • Prefer not to say
Q30
ランク付け

Please rank the reasons you switched providers, from most to least important.

  1. Poor fit with provider
  2. Wait times were too long
  3. Cost or insurance issues
  4. Schedule didn't work
  5. Provider left or changed network
  6. Preferred telehealth
  7. Location or transportation
ドラッグして順位を付ける
Q31
選択式

How do you describe your race or ethnicity? Select all that apply.

  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Hispanic or Latino/a/x
  • Middle Eastern or North African
  • Native Hawaiian or Other Pacific Islander
  • White
  • Multiple races/ethnicities
  • Other
  • Prefer not to say

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

  • Combines structured access/affordability questions (wait times, cost, insurance, barriers) with an adaptive AI follow-up interview that can probe deeper into a respondent's specific provider-fit or telehealth experience.
  • Includes ranking questions on provider-switching reasons and provider-selection priorities, giving quantifiable trade-off data most static mental health templates skip.
  • Covers the full patient journey in one flow — appointment access, provider fit (expertise, listening, clarity, comfort), telehealth comparison, cost, and future care intent — plus a closing open-text reflection question.
  • Pairs quantitative opinion-scale and multiple-choice items with an AI-moderated qualitative interview and auto-generated report, so health systems/insurers get both statistical and narrative insight from one instrument.

SurveySparrow

Mental Health Assessment Template For Adults

This template is oriented toward assessing an adult's current mental health status rather than access barriers, provider fit, or telehealth/cost experience. It's a fielding-ready static form, but its focus differs meaningfully from an access-and-delivery survey. Useful for symptom screening, less so for health-system service-delivery research.

優れている点

  • Ready-to-use template built for adult respondents
  • Likely simple to deploy quickly via SurveySparrow's platform
  • Focused, single-purpose assessment format

物足りない点

  • No indication of adaptive AI follow-up probing — respondents answer fixed questions only
  • Does not appear to cover wait times, telehealth comparison, or affordability, which are central to service-delivery research
  • No transparent AI-prompt methodology or automated qualitative reporting

Jotform

400+ Mental Health Forms

This is a large directory/category page of mental-health-related forms rather than a single fielding-ready survey on access and provider fit — a researcher would need to hunt through hundreds of forms and likely customize heavily. Strong for intake/clinical paperwork use cases, weak as a purpose-built access-barriers instrument.

優れている点

  • Very large form library covering many mental-health use cases
  • Drag-and-drop form builder for customization
  • Likely includes intake and consent-style forms useful for clinics

物足りない点

  • No single template specifically designed around access barriers, wait times, or provider-patient fit
  • Static form logic only — no adaptive AI interview or voice AI component
  • No built-in quality scoring or automated qualitative analysis of responses

QuestionPro

Top 40 Mental Health Survey Questions for Questionnaire + Sample Template

This is primarily a guide/blog listing sample questions with an accompanying template, rather than a dedicated, ready-to-field instrument on access and provider fit. It can inform question design but isn't purpose-built for benchmarking wait times, telehealth, and affordability together. Good as a reference resource, less so as a deployable research tool.

優れている点

  • Broad question bank covering general mental health topics
  • Educational content explaining question rationale
  • Backed by an established survey platform with distribution tools

物足りない点

  • Presented as a question list/guide, not a single cohesive fielding-ready survey flow
  • No adaptive AI interviewing or voice AI to explore individual patient experiences
  • No transparent prompt methodology or automated per-response quality scoring

SurveyMonkey

Mental Health Survey Template & Questions

A genuine ready-to-use mental health survey template from an established platform, suitable for general mental health sentiment or workplace-style surveys. It appears broader and less specialized than a dedicated care-access/provider-fit/telehealth instrument, and offers no AI-driven follow-up. Reasonable starting point but likely requires significant customization for health-system access research.

優れている点

  • Established, easy-to-deploy survey platform with broad distribution reach
  • Ready-made template reduces setup time
  • Familiar interface for respondents and researchers

物足りない点

  • Static question set with no adaptive AI follow-up or voice AI interview option
  • No indication of dedicated modules for wait times, telehealth comparison, or out-of-pocket cost detail
  • No automated quality scoring or AI-generated qualitative reporting

よくあるご質問

「Mental Health Care Access & Provider Fit Survey」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31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 participating in this survey about mental health care access and experiences. This survey is…」・「In the last 12 months, did you try to get mental health care?」・「How well did your most recent provider's expertise match your needs?」。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、31問を約13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。

関連テンプレート

似たテーマのほかの調査もご覧ください。

すべて見る