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すべてのテンプレート
Industry-Specific

New Therapy Client Psychology Intake Assessment

A pre-first-session intake for therapy and counseling practices, covering presenting concerns, symptom frequency, daily-life impact, treatment history, and goals for care. An AI follow-up interview explores the story behind the client's main concern — what changed recently, what they've tried, and what a good outcome looks like — so clinicians arrive at session one already oriented.

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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14問・約7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 what's bringing you here so your therapist can prepare. Your responses are completely confidential and anonymized. This takes about 6-8 minutes, and there are no wrong answers — please answer as honestly as you can.

Q02
同意必須

Before we begin, please confirm you understand how this information will be used.

Q03
選択式必須

What brings you to seek support right now? (Select all that apply)

  • Anxiety or worry
  • Low mood or depression
  • Relationship difficulties
  • Work, school, or career stress
  • Grief or loss
  • A past or ongoing traumatic experience
  • Sleep difficulties
  • Substance use
  • Self-esteem or identity concerns
Q04
自由回答（長文）

In your own words, what's been going on that led you to seek support right now?

Q05
マトリクス必須

Over the last 2 weeks, how often have you experienced each of the following?

6行 × 4列
  • Trouble falling or staying asleep
  • Feeling anxious or on edge
  • Feeling down or hopeless
  • Difficulty concentrating
  • Irritability or anger
  • ほか1件
列: Not at all · Several days · More than half the days · Nearly every day
Q06
オピニオンスケール必須

Overall, how would you rate your emotional wellbeing over the past month?

スケール: 0 – 10
最小:As bad as it gets最大:As good as it gets
Q07
スライダーマトリクス

How much has what you described affected the following areas of your life recently?

5行（各行にスライダー1つ）
  • Work or school performance
  • Relationships with family or friends
  • Sleep
  • Physical health
  • Ability to enjoy daily activities
スライダー 0〜10最小:Not affected at all最大:Severely affected
Q08
選択式必須

Which of these currently apply to you?

  • Currently seeing a therapist or counselor
  • Have seen one in the past but not currently
  • Currently taking medication prescribed for a mental health condition
  • Have taken such medication in the past
Q09
AIインタビュー

Explore the client's primary presenting concern in depth: what changed recently that brought them to seek help now, how long they've noticed the issue, what they've already tried on their own to cope, and what a good outcome from therapy would look like to them. If they disclose thoughts of self-harm, suicide, or being in immediate danger, do not probe further clinically — acknowledge with care, clearly direct them to contact emergency services or a crisis line right away, and end that line of questioning.

Q10
ランク付け

Rank the following goals in order of what you'd most like to focus on in therapy, from most to least important.

  1. Reduce anxiety or worry
  2. Improve mood
  3. Better manage stress
  4. Improve relationships
  5. Process a difficult past experience
  6. Build coping skills
  7. Improve sleep
  8. Better understand myself
ドラッグして順位を付ける
Q11
自由回答（短文）

Is there anything else you'd like your therapist to know before your first session?

Q12
選択式

What is your age range? (Optional — helps your therapist tailor their approach)

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q13
選択式

What is your gender identity? (Optional)

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q14
メッセージ

Thank you for sharing this with us — we know it isn't always easy. Your therapist will review these answers before your first session so you can spend that time on what matters most to you.

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

  • Uses a consent step and welcome message to set an ethical, transparent tone before any clinical questions are asked
  • Combines structured screening (symptom-frequency matrix, wellbeing rating, impact sliders) with an open-ended narrative question so clinicians get both quantifiable and qualitative context
  • Includes an AI follow-up interview that specifically probes the story behind the presenting concern — what changed recently, what's been tried, and what a good outcome looks like — so the therapist isn't starting from zero at session one
  • Ends with a ranking of therapy goals, optional demographic questions, and a closing message from the practice, giving therapists a prioritized, respectful, session-ready summary

SurveyMonkey

Client Intake Form Template

A generic, industry-agnostic client intake template rather than one built for mental health or counseling settings. It's fielding-ready as a basic form but has no clinical language around presenting concerns, symptom frequency, or treatment history. Useful as a starting point that a practice would need to substantially customize.

優れている点

  • Quick to deploy generic intake form
  • Backed by SurveyMonkey's established survey infrastructure and reporting
  • Broad applicability across business types

物足りない点

  • Not designed for mental health/therapy intake — lacks symptom, impact, and treatment-history structure
  • Static question set with no adaptive follow-up to explore a client's story
  • No transparent prompt methodology or automated quality scoring of open responses

SurveySparrow

Sample client intake form template

Another general-purpose client intake template, positioned for business use broadly rather than therapy or counseling practices specifically. It offers a printable/conversational form format but no clinical framing for pre-session mental health intake. Would require significant rework to cover symptom screening or treatment goals.

優れている点

  • Conversational form style that can feel less clinical/intimidating
  • Printable option for in-office use
  • Flexible across business use cases

物足りない点

  • No mental-health-specific content (symptom frequency, daily-life impact, treatment history)
  • No adaptive AI interview to explore the presenting concern further
  • No built-in quality scoring or auto-generated clinical summary report

よくあるご質問

「New Therapy Client Psychology Intake 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14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 what's bring…」・「Before we begin, please confirm you understand how this information will be used.」・「What brings you to seek support right now? (Select all that apply)」。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、14問を約7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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