Q01
Message
All templatesHealthcare & 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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
28 questions · ~12 min
Q02
Multiple Choice
Have you ever participated in a teletherapy session (e.g., by video, phone, or text/chat)?
- Yes
- No
Q03
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
- Other (please specify)
Q04
Dropdown
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
Opinion Scale
How would you rate the overall audio and video connection quality during your teletherapy sessions in the past 3 months?
Scale: 1 – 7
Min:Very poorMax:Excellent
Q06
Message
The following questions ask how things have changed since you started teletherapy. Please answer based on your overall experience.
Q07
Opinion Scale
Overall, how satisfied are you with your teletherapy experience?
Scale: 1 – 7
Min:Not at all satisfiedMax:Extremely satisfied
Q08
Long Text
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
Dropdown
What is your age?
- Under 18
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65 or older
- Prefer not to say
Q10
Message
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
Opinion Scale
How likely are you to try teletherapy in the next 3 months?
Scale: 1 – 7
Min:Very unlikelyMax:Very likely
Q12
Dropdown
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
Opinion Scale
How comfortable did you feel sharing personal information during your teletherapy sessions in the past 3 months?
Scale: 1 – 7
Min:Not at all comfortableMax:Very comfortable
Q14
Opinion Scale
Since starting teletherapy, how have your anxiety or stress levels changed?
Scale: 1 – 7
Min:Much worseMax:Much improved
Q15
Opinion Scale
How likely are you to recommend teletherapy to someone who could benefit from therapy?
Scale: 1 – 7
Min:Not at all likelyMax:Extremely likely
Q16
AI Interview
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
Multiple Choice
Which best describes your gender?
- Woman
- Man
- Non-binary
- Another identity (please describe below)
- Prefer not to say
Q18
Multiple Choice
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
Opinion Scale
How concerned were you about the privacy of your teletherapy sessions in the past 3 months?
Scale: 1 – 7
Min:Not at all concernedMax:Extremely concerned
Q20
Opinion Scale
Since starting teletherapy, how has your overall mood changed?
Scale: 1 – 7
Min:Much worseMax:Much improved
Q21
Multiple Choice
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
Long Text
If you selected 'Another identity' above, please describe your gender here.
Q23
Dropdown
Which device did you primarily use for teletherapy in the past 3 months?
- Smartphone
- Laptop or desktop computer
- Tablet
- Other (please specify)
Q24
Opinion Scale
Since starting teletherapy, how has your ability to cope with daily challenges changed?
Scale: 1 – 7
Min:Much worseMax:Much improved
Q25
Dropdown
Where do you currently live?
- North America
- Europe
- Latin America & Caribbean
- Africa
- Middle East
- Asia
- Oceania
- Prefer not to say
Q26
Opinion Scale
Since starting teletherapy, how has the quality of your personal relationships changed?
Scale: 1 – 7
Min:Much worseMax:Much improved
Q27
Dropdown
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
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 or health
- Retired
- Homemaker or caregiver
- Prefer not to say
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 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 FormsThis 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.
What it does well
- 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
Where it falls short
- 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
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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