すべてのテンプレート
Healthcare & Clinical

Teletherapy Access, Experience & Outcomes Assessment

Evaluates patient access barriers, session comfort, perceived therapeutic outcomes, and format preferences for teletherapy. Designed for healthcare organizations and telehealth platforms seeking to improve virtual care 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28問・約12分
Q01
メッセージ

Welcome to this survey about your experiences with teletherapy (therapy conducted by video, phone, or text/chat). This survey takes approximately 12 minutes to complete. Your participation is entirely voluntary, and you may stop at any time. There are no right or wrong answers — we are interested only in your honest opinions and experiences. All responses are confidential, will be anonymized, and reported only in aggregate. By continuing, you agree to participate in this research.

Q02
選択式

Have you ever participated in a teletherapy session (e.g., by video, phone, or text/chat)?

  • Yes
  • No
Q03
選択式

What are the main reasons you have not used teletherapy so far? Select all that apply.

  • I prefer in-person therapy
  • I'm not sure how to get started
  • Privacy concerns at home or work
  • Not comfortable with technology
  • Cost or insurance concerns
  • No suitable device or internet connection
  • Teletherapy not available with my provider
  • Concerns about quality or effectiveness
  • I don't need therapy right now
  • Other (please specify)
Q04
プルダウン

Approximately how many teletherapy sessions have you had in the past 3 months?

  • 0 (none in this period)
  • 1–2
  • 3–5
  • 6–10
  • 11–20
  • More than 20
Q05
オピニオンスケール

How would you rate the overall audio and video connection quality during your teletherapy sessions in the past 3 months?

スケール: 1 – 7
最小:Very poor最大:Excellent
Q06
メッセージ

The following questions ask how things have changed since you started teletherapy. Please answer based on your overall experience.

Q07
オピニオンスケール

Overall, how satisfied are you with your teletherapy experience?

スケール: 1 – 7
最小:Not at all satisfied最大:Extremely satisfied
Q08
自由回答(長文)

Based on your responses in this survey, what could make teletherapy work better for you? Please share any additional thoughts or feelings about your experience.

Q09
プルダウン

What is your age?

  • Under 18
  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65 or older
  • Prefer not to say
Q10
メッセージ

Thank you for completing this survey. Your responses have been recorded and will be kept confidential. Your feedback helps improve teletherapy services for everyone.

Q11
オピニオンスケール

How likely are you to try teletherapy in the next 3 months?

スケール: 1 – 7
最小:Very unlikely最大:Very likely
Q12
プルダウン

When was your most recent teletherapy session?

  • Within the past week
  • 1–2 weeks ago
  • 3–4 weeks ago
  • 1–2 months ago
  • 3 months ago or longer
Q13
オピニオンスケール

How comfortable did you feel sharing personal information during your teletherapy sessions in the past 3 months?

スケール: 1 – 7
最小:Not at all comfortable最大:Very comfortable
Q14
オピニオンスケール

Since starting teletherapy, how have your anxiety or stress levels changed?

スケール: 1 – 7
最小:Much worse最大:Much improved
Q15
オピニオンスケール

How likely are you to recommend teletherapy to someone who could benefit from therapy?

スケール: 1 – 7
最小:Not at all likely最大:Extremely likely
Q16
AIインタビュー

We'd like to understand your teletherapy experience in more depth. An AI moderator will ask a couple of brief follow-up questions based on your earlier responses.

Q17
選択式

Which best describes your gender?

  • Woman
  • Man
  • Non-binary
  • Another identity (please describe below)
  • Prefer not to say
Q18
選択式

Which formats have you used for teletherapy in the past 3 months? Select all that apply.

  • Video call
  • Phone call
  • Text/chat-based
  • Email-based
  • Online group sessions
  • Other (please specify)
Q19
オピニオンスケール

How concerned were you about the privacy of your teletherapy sessions in the past 3 months?

スケール: 1 – 7
最小:Not at all concerned最大:Extremely concerned
Q20
オピニオンスケール

Since starting teletherapy, how has your overall mood changed?

スケール: 1 – 7
最小:Much worse最大:Much improved
Q21
選択式

For your future therapy sessions, which format would you prefer?

  • Mostly teletherapy
  • Mostly in-person
  • A mix of both
  • No preference
  • Not planning to continue therapy
Q22
自由回答(長文)

If you selected 'Another identity' above, please describe your gender here.

Q23
プルダウン

Which device did you primarily use for teletherapy in the past 3 months?

  • Smartphone
  • Laptop or desktop computer
  • Tablet
  • Other (please specify)
Q24
オピニオンスケール

Since starting teletherapy, how has your ability to cope with daily challenges changed?

スケール: 1 – 7
最小:Much worse最大:Much improved
Q25
プルダウン

Where do you currently live?

  • North America
  • Europe
  • Latin America & Caribbean
  • Africa
  • Middle East
  • Asia
  • Oceania
  • Prefer not to say
Q26
オピニオンスケール

Since starting teletherapy, how has the quality of your personal relationships changed?

スケール: 1 – 7
最小:Much worse最大:Much improved
Q27
プルダウン

What is the highest level of education you have completed?

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

What is your current employment status?

  • Employed full-time
  • Employed part-time
  • Self-employed
  • Student
  • Unemployed and seeking work
  • Not working due to disability or health
  • Retired
  • Homemaker or caregiver
  • 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

  • Includes an adaptive AI follow-up interview that lets patients elaborate on their teletherapy experience in their own words, beyond fixed-choice answers
  • Covers the full journey from access barriers and format/device usage to session comfort, privacy concerns, and connection quality
  • Tracks perceived therapeutic outcomes (anxiety, mood, coping, relationship quality) with dedicated before/after opinion-scale items, plus overall satisfaction and likelihood to recommend
  • Closes with an open-text question asking what could make teletherapy work better, giving healthcare orgs qualitative improvement input alongside automated quality scoring and auto-generated reports

Jotform

600+ Healthcare Assessment Forms

This is a broad directory/category page listing hundreds of healthcare assessment form templates rather than a single ready-to-field teletherapy experience survey. It's useful as a starting point for generic intake or assessment forms, but nothing here is purpose-built around teletherapy access, comfort, or outcomes. Teams would need to build and customize a teletherapy-specific instrument from a generic form base.

優れている点

  • Very large, categorized library of healthcare-related form templates
  • Familiar drag-and-drop form builder widely used by clinics and healthcare admins
  • Likely supports HIPAA-friendly form options common across Jotform's healthcare template set

物足りない点

  • No teletherapy-specific template covering access barriers, session comfort, or therapeutic outcome tracking — this is a generic form category, not a fielding-ready survey
  • Static form fields only, with no adaptive AI follow-up probing or voice AI interview capability
  • No automated per-response quality scoring or auto-generated analytical reporting

よくあるご質問

「Teletherapy Access, Experience & Outcomes 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28問含まれており、最初の設問は次のとおりです:「Welcome to this survey about your experiences with teletherapy (therapy conducted by video, phone, or text/chat). This s…」・「Have you ever participated in a teletherapy session (e.g., by video, phone, or text/chat)?」・「What are the main reasons you have not used teletherapy so far? 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、28問を約12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。

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