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Mental Health Care Access & Provider Fit Survey Template

Capture barriers to care, provider match, telehealth, quality, wait times, and costs. Ready-to-use survey template to optimize mental health services.

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

28

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
In the last 12 months, did you try to get mental health care?
  • Yes, I saw a provider
  • Yes, I tried but did not get an appointment
  • No
  • Prefer not to say
Q2
Multiple Choice
Which type(s) of mental health provider did you see in the last 12 months? Select all that apply.
  • Psychiatrist (MD/DO)
  • Psychologist (PhD/PsyD)
  • Therapist/Counselor (e.g., LCSW, LMFT, LPC)
  • Primary care clinician
  • Psychiatric nurse practitioner
  • Clinical social worker
  • Group therapy program
  • Other
  • Not applicable—I did not see a provider
Q3
Numeric
About how many mental health appointments did you have in the last 12 months? (Enter a whole number; enter 0 if none.)
Accepts a numeric value
Whole numbers only
Q4
Opinion Scale
How likely are you to seek mental health care in the next 6 months?
Range: 1 – 10
Min: Very unlikelyMid: Neither likely nor unlikelyMax: Very likely
Q5
Multiple Choice
Attention check: To confirm you are paying attention, please select "Yes".
  • Yes
  • No
Q6
Rating
How well did your provider’s expertise match your needs?
Scale: 11 (star)
Min: Poor matchMax: Excellent match
Q7
Matrix
Please rate your most recent provider on the following:
RowsVery poorPoorFairGoodExcellent
Treated me with respect•••••
Listened carefully•••••
Explained things clearly•••••
Included my goals in care•••••
Cultural sensitivity•••••
Coordinated with my other care•••••
Q8
Multiple Choice
In the last 12 months, did you switch mental health providers?
  • Yes
  • No
  • Not applicable
Q9
Ranking
If yes, rank the main reasons you switched (top = most important).
Drag to order (top = most important)
  1. Poor fit with provider
  2. Wait times were too long
  3. Cost or insurance issues
  4. Schedule didn’t work
  5. Provider left or changed network
  6. Preferred telehealth
  7. Location or transportation
Q10
Dropdown
How long did you wait for your most recent new-patient appointment?
  • Same week
  • 1-2 weeks
  • 3-4 weeks
  • 1-2 months
  • 3+ months
Q11
Multiple Choice
Which barriers, if any, kept you from getting an appointment? Select all that apply.
  • No providers taking new patients
  • Waitlist too long
  • Cost too high or insurance not accepted
  • Couldn’t find a provider who fit my needs
  • Available times didn’t fit my schedule
  • Transportation or distance
  • Uncomfortable seeking care
  • Technology barriers
  • Other
  • None of the above
Q12
Dropdown
What was the longest wait you encountered when trying to get care?
  • Same week
  • 1-2 weeks
  • 3-4 weeks
  • 1-2 months
  • 3+ months
  • Never got an appointment
Q13
Multiple Choice
What might keep you from seeking care in the next 6 months? Select all that apply.
  • I feel fine/no need
  • Prefer self-help or informal support
  • Privacy or stigma concerns
  • Cost or coverage
  • Unsure how to get started
  • Scheduling or transportation
  • Past negative experience
  • Don’t trust providers
  • Other
  • Nothing likely to prevent me
Q14
Multiple Choice
In the last 12 months, did you use telehealth (video or phone) for mental health care?
  • Yes, video visits
  • Yes, phone calls
  • Yes, both
  • No
Q15
Matrix
Compared with in-person visits, telehealth was...
RowsMuch worseWorseAbout the sameBetterMuch better
More convenient•••••
Easier to talk openly•••••
Protected my privacy•••••
Helped with scheduling flexibility•••••
Had good audio/video quality•••••
Q16
Multiple Choice
How do you usually pay for mental health care?
  • Employer-sponsored insurance
  • Individual/Marketplace plan
  • Medicaid
  • Medicare
  • Student plan
  • Military/VA (e.g., TRICARE)
  • Uninsured/self-pay
  • Other
  • Prefer not to say
Q17
Numeric
About how much did you pay out of pocket for your most recent mental health visit? (USD; enter a whole number)
Accepts a numeric value
Whole numbers only
Q18
Opinion Scale
Overall, my mental health care costs were affordable.
Range: 1 – 10
Min: Strongly disagreeMid: NeutralMax: Strongly agree
Q19
Constant Sum
Allocate 100 points across the options to show what matters most when matching you with a provider.
Total must equal 100
  • Expertise that matches my concerns
  • Appointments available soon
  • Insurance accepted/low out-of-pocket cost
  • Good communication style/rapport
  • Cultural or language match
  • Telehealth availability
  • Location/convenience
Min per option: 0Whole numbers only
Q20
Multiple Choice
What is your age?
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65+
  • Prefer not to say
Q21
Multiple Choice
Which best describes your gender?
  • Woman
  • Man
  • Non-binary or gender diverse
  • Prefer not to say
Q22
Dropdown
Where do you live?
  • United States
  • Canada
  • United Kingdom
  • Australia
  • European Union
  • Other
Q23
Multiple Choice
What is the highest level of education you have completed?
  • Less than high school
  • High school or GED
  • Some college/Associate degree
  • Bachelor’s degree
  • Graduate or professional degree
  • Prefer not to say
Q24
Multiple Choice
What is your current employment status?
  • Full-time
  • Part-time
  • Self-employed
  • Student
  • Unemployed
  • Homemaker
  • Retired
  • Unable to work
  • Prefer not to say
Q25
Multiple Choice
How do you describe your race or ethnicity? Select all that apply.
  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Hispanic or Latino/a/x
  • Middle Eastern or North African
  • Native Hawaiian or Other Pacific Islander
  • White
  • Multiple races/ethnicities
  • Other
  • Prefer not to say
Q26
Long Text
Any final comments about your experience getting or receiving mental health care?
Max 600 chars
Q27
AI Interview
AI Interview: 2 Follow-up Questions on your care experience
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Q28
Chat Message
Thank you for completing the survey! Your feedback helps improve access and provider matching.

Frequently Asked Questions

What is QuestionPunk?
QuestionPunk is a lightweight survey platform for live AI interviews you control. It's fast, flexible, and scalable—adapting every question in real time, moderating responses across languages, letting you steer prompts, models, and flows, and even generating surveys from a simple prompt. Get interview-grade insight with survey-level speed across qual and quant.
How do I create my first survey?
Sign up, then decide how you want to build: let the AI generate a survey from your prompt, pick a template, or start from scratch. Choose question types, set logic, and preview before sharing.
How can I share surveys with my team?
Send a project link so teammates can view and collaborate instantly.
Can the AI generate a survey from a prompt?
Yes. Provide a prompt and QuestionPunk drafts a survey you can tweak before sending.
How long does support typically take to reply?
We reply within 24 hours—often much sooner. Include key details in your message to help us assist you faster.
Can I export survey results?
Absolutely. Export results as CSV straight from the results page for quick data work.

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