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Industry-Specific

Pre-Visit Psychiatric Evaluation Intake Questionnaire

A pre-appointment intake for mental health clinics that captures a patient's presenting concern, symptom frequency across common domains, functional impact, safety status, and treatment history before a first psychiatric visit. An AI follow-up interview reconstructs concrete recent examples behind the ratings and checks in sensitively on any safety responses. Not a substitute for crisis assessment.

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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

Thanks for taking a few minutes before your appointment. These questions help your provider understand what's going on before you meet, and there are no right or wrong answers — honesty helps most. Your responses are completely confidential and anonymized. About 6-8 minutes. This is not a crisis service: if you are in immediate danger, please contact emergency services or a crisis line right now instead of continuing.

Q02
自由回答（長文）必須

In your own words, what's the main concern that brought you to seek this evaluation?

Q03
選択式必須

How long have you been dealing with this concern?

  • Less than 2 weeks
  • 2 weeks to 1 month
  • 1 to 6 months
  • 6 to 12 months
  • More than a year
  • This is a recurring issue I've dealt with before
Q04
マトリクス必須

Over the past two weeks, how often have you experienced each of the following?

8行 × 4列
  • Low mood or sadness
  • Feeling anxious or on edge
  • Irritability or anger
  • Trouble sleeping
  • Appetite or weight changes
  • ほか3件
列: Not at all · Several days · More than half the days · Nearly every day
Q05
オピニオンスケール必須

How much have these concerns interfered with your daily life (work, school, relationships, or self-care) in the last two weeks?

スケール: 0 – 10
最小:Not at all最大:Completely unable to function
Q06
選択式必須

In the past two weeks, how often have you had thoughts that you would be better off dead or of hurting yourself in some way?

  • Not at all
  • Several days
  • More than half the days
  • Nearly every day
Q07
選択式

Are you currently taking any medication prescribed for a mental health condition?

  • Yes
  • No
  • Not sure
Q08
選択式

Which best describes your prior mental health treatment history?

  • No previous treatment
  • Outpatient therapy only
  • Medication only
  • Both therapy and medication
  • Inpatient or crisis-level care
  • Not sure / prefer not to specify
Q09
選択式

What are you hoping this evaluation leads to? Select all that apply.

  • A clearer understanding of what's going on
  • Medication options
  • Therapy or coping strategies
  • Support during a difficult life event
  • A formal diagnosis
Q10
AIインタビュー

Explore the respondent's main presenting concern in depth: when it started, what triggered or worsened it, and what has changed in the last two weeks. If they indicated any thoughts of self-harm as occurring more than 'not at all', gently ask how they are keeping safe right now and clearly note that if they are in immediate danger they should contact emergency services or a crisis line rather than continue. Anchor follow-up on one or two concrete recent examples (a specific day, interaction, or event) rather than general feelings, and note any gap between how they described the problem in their own words and how they rated its severity.

Q11
選択式

What is your age range? (optional, for clinical context)

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q12
選択式

What is your gender identity? (optional, for clinical context)

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q13
選択式

Which best describes your current living situation?

  • Live alone
  • Live with partner or spouse
  • Live with family
  • Live with roommates
  • Other
  • Prefer not to say
Q14
メッセージ

Thank you for sharing this — your responses will be reviewed by your provider before your appointment to help focus your time together. If anything changes before then, especially around your safety, please reach out to a crisis line or emergency services right away.

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 concern, symptom frequency across common domains, functional impact, safety status, and treatment history in one structured pre-visit flow
  • Includes an AI follow-up interview that reconstructs concrete recent examples behind ratings and checks in sensitively on any safety-related responses, rather than leaving flagged answers unexplored
  • Uses transparent prompts and automated per-response quality scoring so clinicians receive a fuller, more consistent picture before the first visit
  • Closes with a clear message explaining that responses will be reviewed by the provider before the appointment, setting appropriate expectations for a clinical (not crisis) context

Jotform

Psychiatric Evaluation Form Template

A static, fielding-ready form template covering standard psychiatric evaluation fields that clinics can customize with Jotform's form builder. It's a fixed questionnaire rather than an interview, so all follow-up and clarification has to be done manually by staff. Good for quick deployment but offers no built-in mechanism to probe deeper on any given answer.

優れている点

  • Ready-to-use template that can be deployed quickly without building from scratch
  • Customizable form fields and layout via Jotform's drag-and-drop builder
  • Likely integrates with Jotform's broader form ecosystem (e-signatures, conditional logic, notifications)

物足りない点

  • No adaptive AI follow-up interview to reconstruct concrete examples behind answers
  • No voice AI interview option
  • No automated per-response quality scoring or auto-generated clinical-ready reports

Typeform

Psychiatric Evaluation Form Template

A conversational-style static form template for psychiatric evaluation intake, built on Typeform's one-question-at-a-time interface. It offers a smoother respondent experience than a traditional form but still relies on fixed questions with no dynamic probing of responses. Safety-related answers would need manual clinical review with no automated sensitive check-in built in.

優れている点

  • Polished, respondent-friendly conversational UI that may improve completion rates
  • Easy to customize question wording and branding within Typeform
  • Supports basic logic branching between questions

物足りない点

  • No adaptive AI follow-up interview or voice AI interview to explore concerns in depth
  • No automated sensitive check-in on safety-related responses
  • No automated per-response quality scoring or auto-generated reports for clinicians

よくあるご質問

「Pre-Visit Psychiatric Evaluation Intake Questionnaire」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：「Thanks for taking a few minutes before your appointment. These questions help your provider understand what's going on b…」・「In your own words, what's the main concern that brought you to seek this evaluation?」・「How long have you been dealing with this concern?」。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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