Q01
Long Text
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Mental Health Care Access & Provider Fit Survey
Assesses barriers to mental health care, provider-patient fit, telehealth preferences, wait times, and affordability. Designed for health systems, insurers, and researchers seeking to identify actionable improvements in mental health service delivery.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
31 questions · ~4 min
Q02
Multiple Choice
In the last 12 months, did you try to get mental health care?
Q03
Long Text
How well did your most recent provider's expertise match your needs?
Q04
Long Text
How long did you wait for your most recent new-patient mental health appointment?
Q05
Multiple Choice
In the last 12 months, did you use telehealth (video or phone) for mental health care?
Q06
Multiple Choice
How do you usually pay for mental health care?
Q07
Multiple Choice
What, if anything, might keep you from seeking mental health care in the next 6 months? Select all that apply.
Q08
Long Text
Please rank the following from most to least important when choosing a mental health provider.
Q09
Long Text
Based on your responses in this survey, please share any additional thoughts or feelings about your experience getting or receiving mental health care.
Q10
Long Text
What is your age?
Q11
Long Text
Thank you for completing this survey. Your responses are confidential and will be used to help improve mental health care access and provider matching. If you are currently experiencing a mental health crisis, please contact the 988 Suicide & Crisis Lifeline by calling or texting 988.
Q12
Multiple Choice
Which type(s) of mental health provider did you see in the last 12 months? Select all that apply.
Q13
Long Text
My most recent provider listened carefully to my concerns.
Q14
Multiple Choice
Which of the following, if any, made it difficult for you to get a mental health appointment? Select all that apply.
Q15
Long Text
Compared with in-person visits, telehealth was more convenient.
Q16
Long Text
Approximately how much did you pay out of pocket for your most recent mental health visit?
Q17
Long Text
How likely are you to seek mental health care in the next 6 months?
Q18
AI Interview
We'd like to learn a bit more about your mental health care experience. An AI moderator will ask a couple of brief follow-up questions.
Q19
Multiple Choice
Which best describes your gender?
Q20
Long Text
Approximately how many mental health appointments did you have in the last 12 months?
Q21
Long Text
My most recent provider explained treatment options clearly.
Q22
Long Text
Compared with in-person visits, the quality of care via telehealth was just as good.
Q23
Long Text
Overall, my mental health care costs were affordable.
Q24
Long Text
Where do you currently live?
Q25
Long Text
My most recent provider made me feel comfortable and respected.
Q26
Long Text
Compared with in-person visits, I felt just as comfortable being open and honest during telehealth sessions.
Q27
Long Text
What is the highest level of education you have completed?
Q28
Multiple Choice
In the last 12 months, did you switch mental health providers?
Q29
Long Text
What is your current employment status?
Q30
Long Text
Please rank the reasons you switched providers, from most to least important.
Q31
Multiple Choice
How do you describe your race or ethnicity? Select all that apply.
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.