Q01
Long Text
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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 · ~4 min
Q02
Multiple Choice
Have you ever participated in a teletherapy session (e.g., by video, phone, or text/chat)?
Q03
Multiple Choice
What are the main reasons you have not used teletherapy so far? Select all that apply.
Q04
Long Text
Approximately how many teletherapy sessions have you had in the past 3 months?
Q05
Long Text
How would you rate the overall audio and video connection quality during your teletherapy sessions in the past 3 months?
Q06
Long Text
The following questions ask how things have changed since you started teletherapy. Please answer based on your overall experience.
Q07
Long Text
Overall, how satisfied are you with your teletherapy experience?
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
Long Text
What is your age?
Q10
Long Text
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
Long Text
How likely are you to try teletherapy in the next 3 months?
Q12
Long Text
When was your most recent teletherapy session?
Q13
Long Text
How comfortable did you feel sharing personal information during your teletherapy sessions in the past 3 months?
Q14
Long Text
Since starting teletherapy, how have your anxiety or stress levels changed?
Q15
Long Text
How likely are you to recommend teletherapy to someone who could benefit from therapy?
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?
Q18
Multiple Choice
Which formats have you used for teletherapy in the past 3 months? Select all that apply.
Q19
Long Text
How concerned were you about the privacy of your teletherapy sessions in the past 3 months?
Q20
Long Text
Since starting teletherapy, how has your overall mood changed?
Q21
Multiple Choice
For your future therapy sessions, which format would you prefer?
Q22
Long Text
If you selected 'Another identity' above, please describe your gender here.
Q23
Long Text
Which device did you primarily use for teletherapy in the past 3 months?
Q24
Long Text
Since starting teletherapy, how has your ability to cope with daily challenges changed?
Q25
Long Text
Where do you currently live?
Q26
Long Text
Since starting teletherapy, how has the quality of your personal relationships changed?
Q27
Long Text
What is the highest level of education you have completed?
Q28
Multiple Choice
What is your current employment status?
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.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.