Assess teletherapy access, comfort, satisfaction, and outcomes for online therapy (video or phone). Telehealth patient survey template; 6-8 minutes.
What's Included
AI-Powered Questions
Intelligent follow-up questions based on responses
Automated Analysis
Real-time sentiment and insight detection
Smart Distribution
Target the right audience automatically
Detailed Reports
Comprehensive insights and recommendations
Template Overview
22
Questions
AI-Powered
Smart Analysis
Ready-to-Use
Launch in Minutes
This professionally designed survey template helps you gather valuable insights with intelligent question flow and automated analysis.
Sample Survey Items
Q1
Multiple Choice
Have you ever had a teletherapy session (by video or phone)?
Yes
No
Q2
Multiple Choice
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
Q3
Opinion Scale
How likely are you to try teletherapy in the next 3 months?
Range: 1 – 10
Min: Very unlikelyMid: UnsureMax: Very likely
Q4
Numeric
How many teletherapy sessions have you had in the past 3 months?
Accepts a numeric value
Whole numbers only
Q5
Date
When was your most recent teletherapy session?
Q6
Multiple Choice
Which formats have you used for teletherapy in the past 12 months? Select all that apply.
Video call
Phone call
Text/chat-based
Email-based
Online group sessions
Q7
Dropdown
Which device did you primarily use for teletherapy in the past 3 months?
Smartphone
Laptop/desktop
Tablet
Other
Q8
Rating
Overall audio/video connection quality during teletherapy in the past 3 months.
Scale: 11 (star)
Min: PoorMax: Excellent
Q9
Opinion Scale
How comfortable did you feel sharing personal information during teletherapy in the past 3 months?
Range: 1 – 10
Min: Not comfortableMid: NeutralMax: Very comfortable
Q10
Opinion Scale
How concerned were you about privacy during your teletherapy sessions in the past 3 months?
Range: 1 – 10
Min: Not at allMid: SomewhatMax: Extremely
Q11
Matrix
Compared with before you started teletherapy, how have the following changed?
Rows
Much worse
Slightly worse
No change
Slightly better
Much better
Feeling understood by my therapist
•
•
•
•
•
Symptoms or distress
•
•
•
•
•
Coping skills
•
•
•
•
•
Adherence to my treatment plan
•
•
•
•
•
Progress toward personal goals
•
•
•
•
•
Q12
Multiple Choice
For your future therapy, which option would you prefer?
Mostly teletherapy
Mostly in-person
A mix of both
No preference
Not planning therapy
Q13
Multiple Choice
Attention check: To confirm attention, please select “Agree.”
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Q14
Dropdown
What is your age?
Under 18
18–24
25–34
35–44
45–54
55–64
65 or older
Prefer not to say
Q15
Multiple Choice
Which best describes your gender?
Woman
Man
Non-binary
Another identity (self-describe)
Prefer not to say
Q16
Short Text
Please self-describe your gender.
Max 100 chars
Q17
Dropdown
Where do you currently live?
North America
Europe
Latin America & Caribbean
Africa
Middle East
Asia
Oceania
Prefer not to say
Q18
Dropdown
What is the highest level of education you have completed?
Less than high school
High school or equivalent
Some college/associate degree
Bachelor’s degree
Graduate or professional degree
Prefer not to say
Q19
Multiple Choice
What is your current employment status?
Employed full-time
Employed part-time
Self-employed
Student
Unemployed and seeking work
Not working due to disability/health
Retired
Homemaker/caregiver
Prefer not to say
Q20
Long Text
What could make teletherapy work better for you?
Max 600 chars
Q21
AI Interview
AI Interview: 2 Follow-up Questions on Teletherapy
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Q22
Chat Message
Thank you for completing the survey. Your responses have been recorded.
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