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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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샘플 질문

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질문 14개 · 약 7분
Q01
메시지

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
동의필수

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

Q03
객관식필수

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
매트릭스필수

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

6개 행 × 4개 열
  • Trouble falling or staying asleep
  • Feeling down, low, or hopeless
  • Feeling anxious or on edge
  • Irritability or being easily annoyed
  • Trouble concentrating on tasks
  • 외 1개
열: Not at all · Several days · More than half the days · Nearly every day
Q05
의견 척도필수

How much have these difficulties gotten in the way of your work, relationships, or daily life recently?

척도: 0 – 10
최소:Not at all최대:Completely unable to function
Q06
객관식필수

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
장문형

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

Q08
AI 인터뷰

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
객관식필수

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
순위 매기기

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
드래그하여 순위 지정
Q11
객관식

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
객관식

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
드롭다운

What is your gender identity?

  • Woman
  • Man
  • Non-binary
  • Another identity
  • Prefer not to say
Q14
메시지

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.

포함된 기능

  • AI 후속 질문

    정형화된 설문이 놓치는 세부 내용을, 주관식 답변에 맞춰 AI가 심층 질문으로 끌어냅니다.

  • 주의력 확인 장치

    성의 없는 답변과 저품질 응답자를 걸러내는 내장 안전장치입니다.

  • AI가 작성한 문안

    문구, 질문 순서, 분기 로직까지 AI가 연구 목표에 맞춰 작성합니다.

  • 자동 리포트

    응답이 모이면 주요 주제, 인용문, 이해하기 쉬운 요약이 자동으로 작성됩니다.

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다른 설문 도구의 가장 유사한 템플릿을 검토했습니다. 그 도구들이 잘하는 점과, 이 템플릿이 한발 더 나아가는 지점을 정리했습니다.

이 템플릿을 선택하는 이유

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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

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