Q01
Message
All templates
Biopsychosocial Assessment for Clinical Intake
A structured intake tool for clinicians, counselors, and case managers that maps a client's physical health, mood and coping patterns, and social/environmental context into one whole-person profile. An AI follow-up interview explores the client's self-identified top stressor in their own words, surfacing how biological, psychological, and social factors interact in daily life.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
16 questions · ~8 min
Q02
ConsentRequired
Before we begin, please review this statement.
Q03
Rating ScaleRequired
Right now, how would you rate your overall physical health?
Range: 1 – 5
Min:PoorMax:Excellent
Q04
Slider MatrixRequired
Over the last 2 weeks, how would you rate each of the following?
4 rows, one slider each
- Sleep quality
- Energy level
- Physical pain or discomfort
- Appetite or eating patterns
Slider 0–10Min:Very poorMax:Very good
Q05
Short Text
Please list any current medical conditions, medications, or ongoing treatments (write 'none' if not applicable).
Q06
Multiple ChoiceRequired
In the last 30 days, how often have you used alcohol or other substances to cope with stress or emotions?
- Never
- Rarely
- About once a week
- Several times a week
- Daily
Q07
Opinion ScaleRequired
Over the last 2 weeks, how would you rate your overall stress level?
Scale: 0 – 10
Min:No stress at allMax:Overwhelming stress
Q08
MatrixRequired
In the last 2 weeks, how often have you experienced each of the following?
4 rows × 5 columns
- Feeling anxious or on edge
- Feeling down, hopeless, or unmotivated
- Trouble concentrating or making decisions
- Feeling supported by people around you
Columns: Never · Rarely · Sometimes · Often · Always
Q09
Multiple ChoiceRequired
Which best describes your current living situation?
- Living alone
- Living with family or a partner
- Living with roommates
- Temporary, shared, or unstable housing
- Currently without stable housing
Q10
Multiple ChoiceRequired
In the last 30 days, how often have money worries affected your ability to cover basics like food, housing, or medication?
- Never
- Rarely
- Sometimes
- Often
- Almost always
Q11
Short TextRequired
What is the single biggest source of stress in your life right now?
Q12
AI Interview
Using the respondent's answer about their biggest current stressor, explore how it connects to their physical health, mood, and living situation — ask how it affects their sleep, daily functioning, or relationships, and what they've already tried to manage it. Anchor on any specific frequency or scale answers they gave earlier (sleep, stress, mood, financial strain) and ask them to walk through one concrete recent example. If the respondent expresses thoughts of self-harm, hopelessness, or safety concerns, do not attempt to counsel or diagnose — acknowledge it, gently ask if they are safe right now, and encourage them to contact a crisis line or their care provider before continuing.
Q13
Dropdown
What is your age range?
- Under 18
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65+
- Prefer not to say
Q14
Multiple Choice
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer not to say
Q15
Multiple Choice
What is your current employment status?
- Employed full-time
- Employed part-time
- Unemployed and looking
- Unable to work
- Retired
- Student
- Prefer not to say
Q16
Message
Thank you for sharing all of this. Your responses will go directly to your care team to help build a plan that fits your whole life, not just one part of it.
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
- Goes beyond static fields by using an AI follow-up interview that explores the client's self-identified top stressor in their own words, surfacing how biological, psychological, and social factors interact in daily life
- Combines standardized clinical screening formats (rating, slider matrix, opinion scale, matrix) covering physical health, mood, coping, and stress with open-ended narrative capture
- Screens for high-risk context factors like substance use for coping and financial strain affecting basic needs, alongside living situation and demographics for a whole-person profile
- Frames the intake with a consent step and a warm closing message so clients understand how responses will be used by their care team, supporting transparent, ethical data collection
Jotform
Biopsychosocial Assessment Form TemplateA ready-to-field static form template covering biological, psychological, and social intake domains, built on Jotform's drag-and-drop form builder. It's structured for direct clinical use but relies entirely on fixed fields with no dynamic follow-up capability. Customization is manual, requiring the clinician to edit questions themselves for each client population.
What it does well
- Fielding-ready template usable immediately without custom setup
- Backed by Jotform's broad form-building ecosystem (conditional logic, integrations, e-signatures)
- Familiar, easy-to-edit interface for non-technical clinical staff
Where it falls short
- Static question set with no adaptive AI follow-up to probe a client's stated stressor in their own words
- No automated per-response quality scoring or auto-generated clinical summary report
- No transparent, published interview prompt/methodology for the follow-up questions since none exist
Typeform
Biopsychosocial Assessment Form TemplateTypeform offers a conversational-style, one-question-at-a-time biopsychosocial template that's pleasant to fill out and mobile-friendly. It captures the same broad intake domains but as a fixed sequence of questions rather than an adaptive dialogue. There's no mechanism for the tool itself to explore a client's answers more deeply.
What it does well
- Polished, conversational UI that can reduce respondent friction compared to traditional forms
- Fielding-ready and easy to brand/customize visually
- Good mobile completion experience
Where it falls short
- No adaptive AI interview or voice AI option to explore open-ended answers like a top stressor
- No automated quality scoring per response or auto-generated clinical report
- Question flow is pre-set, so it cannot surface interacting biopsychosocial factors dynamically
SurveySparrow
Counselling Intake Assessment Form Template | Export PDF FormsThis is a counselling-focused intake template with PDF export, aimed at capturing client background for therapists rather than a full biopsychosocial structure specifically. It's a static, fielding-ready form suited to general counselling paperwork. It doesn't offer any AI-driven exploration of a client's presenting stressor.
What it does well
- Fielding-ready and tailored to counselling/intake workflows
- PDF export supports clinical recordkeeping and offline documentation needs
- Likely offers conversational survey formatting typical of SurveySparrow's builder
Where it falls short
- No adaptive AI or voice interview to probe the client's stated top stressor in their own words
- No automated per-response quality scoring or auto-generated whole-person report
- Template is oriented to general counselling intake rather than a structured biological/psychological/social mapping
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.