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Industry-Specific

Psychiatric Intake and Symptom Screening Survey

A pre-appointment intake for mental health practices that captures presenting concerns, symptom frequency over the last two weeks, treatment history, and safety screening before the first visit — with an AI follow-up interview that reconstructs the story behind the symptoms (onset, triggers, what's changed) so clinicians walk in with context instead of a blank checklist.

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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 — thanks for taking a few minutes before your appointment. Your responses are completely confidential and anonymized. These questions help your clinician understand what's going on so your first session can focus on what matters most. Takes about 6-8 minutes, and you can skip anything you'd rather not answer.

Q02
同意必須

Before we start, please review how your responses will be used.

Q03
選択式必須

What is bringing you in for care right now? Select all that apply.

  • Anxiety or excessive worry
  • Low mood or depression
  • Sleep problems
  • Relationship or family stress
  • Substance use
  • Past trauma or a specific event
  • Work or school stress
  • Grief or loss
Q04
マトリクス必須

Over the last 2 weeks, how often have you been bothered by each of the following?

6行 × 4列
  • Trouble falling or staying asleep
  • Feeling down, low, or hopeless
  • Feeling anxious or on edge
  • Irritability or being easily annoyed
  • Trouble concentrating on tasks
  • ほか1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 difficulties gotten in the way of your work, relationships, or daily life recently?

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

What best describes your current involvement with mental health treatment?

  • Currently in therapy
  • Currently taking psychiatric medication
  • Previously received treatment, not currently
  • Never received treatment for this
  • Prefer not to say
Q07
自由回答（長文）

In your own words, what's changed recently that made now feel like the right time to seek help?

Q08
AIインタビュー

Reconstruct the story behind the respondent's presenting concern and symptom pattern: when it started, what triggered or worsened it, what they've already tried on their own, and how it's specifically affecting their daily functioning. If they flagged multiple concerns, ask which one feels most urgent right now. If their symptom answers suggest high frequency or severe functional impact, gently and clearly probe for safety and immediate risk, and note that this should be flagged for clinician review rather than resolved in this interview.

Q09
選択式必須

In the last 2 weeks, have you had any thoughts of harming yourself or someone else?

  • Never
  • Rarely
  • Sometimes
  • Often
  • Yes, and I have a plan
Q10
ランク付け

Rank what you most want out of treatment, from most to least important.

  1. Feeling less anxious or worried
  2. Improving my mood
  3. Sleeping better
  4. Better coping tools for stress
  5. Repairing a relationship
  6. Understanding myself better
  7. Reducing or stopping substance use
ドラッグして順位を付ける
Q11
選択式

Which format of care are you most interested in right now?

  • Individual talk therapy
  • Medication management
  • Group therapy
  • A combination of therapy and medication
  • Not sure yet
Q12
選択式

What is your age range?

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q13
プルダウン

What is your gender identity?

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

Thank you for sharing this — it takes courage. Your responses will be reviewed by your care team before your appointment so your first session can start from where you actually are.

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

  • Includes a symptom-frequency matrix covering the last two weeks plus an impairment rating, paired with an AI follow-up interview that reconstructs onset, triggers, and what's changed — clinicians get narrative context, not just checkbox scores.
  • Built-in safety screening question on thoughts of self-harm or harm to others, plus an upfront consent step and a closing message clarifying that responses are reviewed by a clinician before the visit.
  • Captures treatment history, preferred care format, and a ranked list of what the patient wants out of treatment, combining structured intake data with open-ended qualitative context (in the patient's own words).
  • AI follow-up prompts are transparent and each response is auto-scored for quality, with an auto-generated report for the clinician — capabilities static form builders don't offer.

Jotform

Psychiatric Intake Form Template

A ready-to-field, psychiatric-specific intake form covering history and presenting concerns, with Jotform's usual form-builder flexibility (fields, e-signature, integrations). It's a static document-style form rather than a conversational interview, so all follow-up depends on pre-built fields, not the patient's actual answers.

優れている点

  • Purpose-built for psychiatric intake rather than a generic template
  • Extensive field types and customization typical of Jotform's builder
  • Likely supports e-signature and HIPAA-related form options common on the platform

物足りない点

  • Static form with no adaptive AI follow-up questioning
  • No mechanism to reconstruct the story behind symptoms beyond fixed fields
  • No automated per-response quality scoring or auto-generated clinician report

Typeform

Psychiatric Intake Form

A conversational, one-question-at-a-time psychiatric intake template that's pleasant to fill out on mobile, in Typeform's signature style. Branching logic can tailor which questions appear, but there's no true adaptive interview that probes deeper based on what a patient actually writes.

優れている点

  • Clean, conversational single-question UI likely to improve completion rates
  • Mobile-friendly presentation suited to pre-appointment intake
  • Supports logic jumps to skip/show questions based on prior answers

物足りない点

  • Logic branching is rule-based, not an AI interview that adapts to free-text content
  • No voice interview option or guided screen-share tasks
  • No transparent prompt library or automated quality scoring on responses

SurveyMonkey

Client Intake Form Template

A general-purpose client intake template, not specific to psychiatry or mental health, that would need substantial customization (symptom checklists, safety screening) before it's appropriate for a psychiatric practice. It benefits from SurveyMonkey's broad survey-logic and reporting tools but isn't a clinical-intake template out of the box.

優れている点

  • Backed by SurveyMonkey's mature survey logic and analytics dashboard
  • Easy to distribute across email/web/link channels
  • Familiar builder that non-clinical staff can edit quickly

物足りない点

  • Generic client intake, not tailored to psychiatric symptom screening or safety questions
  • Static question set with no adaptive AI follow-up interview
  • No option for voice AI interviews or guided screen-share tasks

SurveySparrow

Sample client intake form template

A generic business client intake template with a conversational chat-style form experience, not built for psychiatric or clinical use, so symptom screening and safety questions would have to be added from scratch. Useful as a starting shell for a chat-style form but not a fielding-ready mental health intake.

優れている点

  • Chat-style conversational UI similar in feel to a guided interview
  • General intake structure could be adapted for various business/service contexts
  • Likely easy to theme and re-brand for a practice's intake page

物足りない点

  • Not designed for psychiatric symptom frequency or safety screening
  • No adaptive AI questioning — the chat-style flow is scripted, not responsive to content
  • No automated scoring, transparent AI prompts, or auto-generated clinical report

よくあるご質問

「Psychiatric Intake and Symptom Screening 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14問含まれており、最初の設問は次のとおりです：「Welcome — thanks for taking a few minutes before your appointment. Your responses are completely confidential and anonym…」・「Before we start, please review how your responses will be used.」・「What is bringing you in for care 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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