Q01
Message
All templates
Provider Adaptation to Telehealth Licensure & Prescribing Rules
Tracks how clinicians are adjusting to shifting multi-state licensure requirements and controlled-substance prescribing rules for telehealth, including care disruptions and compliance burden. An AI follow-up interview reconstructs a specific recent case where a rule change affected a patient encounter, surfacing details a closed-ended survey would miss.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
Multiple ChoiceRequired
Which best describes your primary clinical role?
- Physician (MD/DO)
- Nurse practitioner
- Physician assistant
- Psychiatrist or other behavioral health prescriber
- Pharmacist
- Other licensed prescriber
Q03
Multiple ChoiceRequired
In the last 30 days, what share of your patient visits were conducted via telehealth (audio or video)?
- None
- Less than 25%
- 25-50%
- 51-75%
- More than 75%
Q04
NumberRequired
In how many states are you currently licensed, credentialed, or otherwise authorized to deliver telehealth care?
Q05
Multiple ChoiceRequired
In the last 6 months, have you had to turn away, delay, or refer out a telehealth patient because you weren't licensed or authorized in their state?
- Yes, more than once
- Yes, once
- No
- Not sure
Q06
MatrixRequired
How much has each of the following recent regulatory changes affected your day-to-day telehealth practice?
4 rows × 4 columns
- Federal rules on prescribing controlled substances via telehealth (e.g., buprenorphine, stimulants)
- State licensure reciprocity or interstate compact participation
- In-person exam requirements before certain prescriptions
- Cross-state insurance or Medicaid telehealth reimbursement rules
Columns: No impact · Minor adjustment · Major adjustment · Stopped offering this entirely
Q07
Opinion ScaleRequired
How confident are you that you currently understand the telehealth prescribing and licensure rules that apply to your practice?
Scale: 1 – 7
Min:Not confident at allMax:Extremely confident
Q08
Multiple Choice
Which of these controlled-substance prescribing changes has affected your practice the most in the last year?
- Buprenorphine or other opioid use disorder treatment via telehealth
- ADHD stimulant prescribing restrictions
- Special registration or in-person exam requirements for telehealth prescribing
- None of these apply to my practice
Q09
AI Interview
Ask the respondent to walk through one specific, recent patient encounter where a telehealth licensure or prescribing rule directly shaped what they could do clinically - what the rule was, what decision they had to make, and what happened to the patient as a result. If they say no rule has ever affected a real case, probe whether they've changed any standing practice out of caution even without a concrete incident, and what that precaution cost them or the patient.
Q10
Multiple Choice
What would most reduce the administrative burden of staying compliant with multi-state telehealth rules for you?
- Automated license and eligibility verification tools
- Dedicated legal or compliance staff support
- Clearer guidance from professional or licensing boards
- Expansion of interstate licensure compacts
- Standardized federal rules replacing state-by-state variation
Q11
Rating Scale
How well does your employer or organization keep you informed about changes to telehealth licensure and prescribing rules?
Range: 1 – 5
Min:Very poorlyMax:Excellent
Q12
Multiple Choice
How many years have you been in clinical practice?
- Less than 2 years
- 2-5 years
- 6-10 years
- 11-20 years
- More than 20 years
- Prefer not to say
Q13
Multiple Choice
Which best describes your primary practice setting?
- Solo or small private practice
- Large group or multi-specialty practice
- Hospital or health system employed
- Direct-to-consumer telehealth company
- Academic medical center
- Other
- Prefer not to say
Q14
Message
That's everything - thank you for sharing your experience. Your responses will be combined with other clinicians' to help identify where telehealth licensure and prescribing rules need clearer guidance or reform.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Includes a dedicated AI follow-up interview that asks clinicians to walk through one specific recent patient encounter affected by a licensure or prescribing rule change, surfacing details a closed-ended form would miss
- Combines quantitative structure (multiple-choice, numeric license count, matrix of regulatory impacts, opinion scale on prescribing rule confidence) with open-ended narrative depth in a single flow
- Captures both compliance burden and care disruption (turning away, delaying, or referring out telehealth patients) rather than just satisfaction or consent status
- Every prompt is transparent and the responses roll up into an auto-generated report, so there's no black-box scoring or manual transcription needed
Jotform
100+ Telehealth FormsThis is a broad category page of 100+ telehealth-related forms (intake, consent, scheduling, feedback) rather than a single fielding-ready survey on licensure or prescribing rules. It's useful as a starting point for building a custom form but requires significant editing to match this topic. No template here is purpose-built around multi-state licensure or controlled-substance rule changes.
What it does well
- Large library of pre-built healthcare form templates to start from
- Drag-and-drop form builder likely allows quick customization
- Covers general telehealth operational needs (intake, consent, scheduling)
Where it falls short
- Static form fields only — no adaptive AI follow-up to probe a specific patient encounter
- No built-in mechanism to reconstruct a narrative case or score response quality
- No template specifically addressing licensure/prescribing compliance burden
Typeform
Telehealth Consent Form TemplateThis is a patient-facing consent form for telehealth visits, not a clinician survey about licensure or prescribing regulation. It's relevant only in that it's a telehealth-adjacent Typeform template; the audience (patients vs. providers) and purpose (legal consent vs. research) differ substantially from this template.
What it does well
- Clean conversational form UI suited for patient-facing consent capture
- Likely simple to deploy for compliance/consent documentation
- Established telehealth template category on the platform
Where it falls short
- Designed for patient consent, not provider research on regulatory adaptation
- No adaptive interview or follow-up questioning to explore specific cases
- No mechanism for scoring, reporting, or analyzing compliance burden across a clinician population
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.