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Referral-to-Treatment Intake Experience Survey

Measures how patients experience the intake journey between referral and first treatment — communication clarity, wait-time transparency, and booking friction — for clinics and healthcare providers managing referral-to-treatment pathways. An AI follow-up interview reconstructs exactly where the process broke down or worked well, beyond a satisfaction score.

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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13問・約7分
Q01
メッセージ

Thanks for taking a few minutes to share your experience so far. Your responses are completely confidential and anonymized. We'd like to understand what it was like between your referral and your first appointment or treatment — there are no right or wrong answers. This should take about 5 minutes.

Q02
選択式必須

How were you referred for your current treatment pathway?

  • GP referral
  • Self-referral
  • Referred by another specialist
  • Online or digital referral form
  • Other
Q03
選択式必須

How long ago were you referred?

  • Less than 2 weeks ago
  • 2-4 weeks ago
  • 1-3 months ago
  • 3-6 months ago
  • More than 6 months ago
Q04
オピニオンスケール必須

How clear was the communication you received about what would happen next after your referral was submitted?

スケール: 1 – 5
最小:Not clear at all最大:Extremely clear
Q05
マトリクス必須

Please rate each part of your intake experience so far.

4行 × 5列
  • Time to first contact from the service after referral
  • Clarity of information about expected wait times
  • Ease of reaching someone with questions
  • Reassurance provided while you waited
列: Poor · Below average · Average · Good · Excellent
Q06
評価スケール必須

How would you rate the ease of booking your first appointment?

範囲: 1 – 5
最小:Very difficult最大:Very easy
Q07
選択式

Did any of the following happen during your intake process? Select all that apply.

  • No delays or issues
  • Appointment was rescheduled
  • Referral was lost or had to be resubmitted
  • Long wait for initial contact from the service
  • Unclear next steps at some point
  • Other
Q08
オピニオンスケール必須

Based on your intake experience so far, how likely are you to recommend this service to someone else needing similar care?

スケール: 0 – 10
最小:Not at all likely最大:Extremely likely
Q09
AIインタビュー

Reconstruct the respondent's actual timeline between referral and now: what communication they received, when, and from whom. If they reported any delay, rescheduling, or unclear next steps, probe exactly what happened, how they found out, and what they had to do to move things forward. Anchor especially on gaps between the clarity rating and the recommend-likelihood score — if communication was rated poorly but they'd still recommend the service (or vice versa), ask why.

Q10
自由回答（短文）

What one change would have made your wait between referral and treatment easier?

Q11
選択式

Which age group do you fall into?

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

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q13
メッセージ

Thank you for sharing your experience. Your answers help this service identify where the referral-to-treatment process needs to improve, and will be reviewed alongside other patients' feedback to guide changes to communication and scheduling.

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

  • Purpose-built to measure the referral-to-treatment journey itself (communication clarity, wait-time transparency, booking friction) rather than just collecting patient details
  • Combines structured questions (multiple choice, opinion scale, matrix, rating) with an AI follow-up interview that reconstructs the respondent's actual timeline and where the process broke down
  • Captures concrete friction points via a 'select all that apply' checklist and a short-text question asking what one change would have eased the wait, giving both quantifiable and narrative data
  • Includes recommend-likelihood and demographic questions plus opening/closing chat messages, so it fields as a complete, ready-to-run survey rather than a bare form

Jotform

Psychedelic Experience Intake Form Template

This is a clinical pre-session intake form for a specific treatment modality (psychedelic therapy), used to collect patient background and health information before a session begins. It is not designed to measure how patients experienced the referral-to-treatment journey, wait times, or booking friction. Useful mainly as a data-collection form rather than an experience/satisfaction survey.

優れている点

  • Healthcare-specific template with fields tailored to a clinical intake context
  • Drag-and-drop form builder with standard field types (checkboxes, text, signature, etc.)

物足りない点

  • Static form with fixed fields — no adaptive follow-up questioning to explore why an answer was given
  • Focused on collecting patient background data, not on reconstructing or scoring the referral-to-treatment experience
  • No mechanism to probe communication breakdowns or booking friction the way an AI follow-up interview would

SurveyMonkey

Client Intake Form Template

A generic client intake form meant to onboard a new client and gather contact/service details, not a survey about the experience of moving from referral to treatment. It could be manually adapted for healthcare use, but as published it isn't scoped to wait-time transparency, communication clarity, or booking friction. It's a fielding-ready form, but for a different purpose than an experience study.

優れている点

  • Simple, quick-to-deploy template on a well-known survey platform
  • Broadly customizable for various client-onboarding use cases

物足りない点

  • No adaptive AI interviewing — follow-up questions require manual branching logic set up in advance
  • Not built around healthcare referral pathways or wait-time/booking-friction measurement specifically
  • No automated per-response quality scoring or auto-generated diagnostic reports

よくあるご質問

「Referral-to-Treatment Intake Experience 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13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 to share your experience so far. Your responses are completely confidential and anonymiz…」・「How were you referred for your current treatment pathway?」・「How long ago were you referred?」。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、13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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