Q01
Message
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Teletherapy From Home Continuation Preferences
Measures whether clients want to keep doing therapy from home by video or phone, shift to a hybrid model, or return to in-person care — and why. Built for behavioral health practices and telehealth platforms deciding how to structure ongoing care; the AI follow-up interview digs into the specific trade-offs, like privacy and connection with the therapist, behind each person's stated preference.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
Multiple ChoiceRequired
In the last 3 months, how have you mainly received your therapy or counseling sessions?
- Entirely video sessions from home
- Entirely phone sessions from home
- A mix of from-home and in-person sessions
- Entirely in-person sessions
Q03
Number
In the last 3 months, roughly how many therapy sessions have you had by video or phone from home?
Q04
Opinion ScaleRequired
Overall, how satisfied are you with doing therapy by video or phone from home?
Scale: 1 – 7
Min:Not at all satisfiedMax:Extremely satisfied
Q05
MatrixRequired
How much do you agree with each statement about attending therapy from home?
5 rows × 5 columns
- I can speak openly and privately during my video/phone sessions
- Video/phone sessions are easier to fit into my schedule
- I feel as connected to my therapist by video/phone as I would in person
- The technology (video, audio, connection) works reliably for my sessions
- Sessions from home cost me less time or money (travel, childcare, time off work)
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q06
Rating Scale
How easy is it to schedule and join your video or phone sessions?
Range: 1 – 5
Min:Very difficultMax:Very easy
Q07
Best–Worst Trade-off (MaxDiff)
Which of these matter most, and least, in deciding how you'd like to attend therapy?
- Not having to travel to an office
- Being in a comfortable, familiar space
- More privacy than a waiting room
- Easier to fit around work or childcare
- Feeling less connected to my therapist
- Technical problems during sessions
- Harder to focus or avoid distractions at home
Pick best & worst per setBest:Matters most to my preferenceWorst:Matters least to my preference
Q08
Multiple ChoiceRequired
Going forward, how would you prefer to attend your therapy sessions?
- Continue entirely from home (video or phone)
- A mix of from-home and in-person sessions
- Return to entirely in-person sessions
- No strong preference either way
Q09
Multiple Choice
Which of the following have gotten in the way of your video or phone sessions?
- Unreliable internet or phone connection
- Lack of privacy at home
- Hard to find a quiet, uninterrupted space
- Scheduling conflicts
- Feeling disconnected from my therapist
- Difficulty using the video platform
Q10
AI Interview
Anchor on the respondent's stated future preference (continue from home, hybrid, in-person, or no preference) and reconstruct the specific reasoning behind it — what a typical from-home session feels like for them, and what would need to change for them to switch formats. If they chose hybrid or 'no preference', probe which situations push them toward video/phone versus in-person. If they reported feeling less connected to their therapist, dig into whether that's about the format itself or the specific therapist relationship.
Q11
Multiple Choice
What is your age range? (optional)
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65+
- Prefer not to say
Q12
Multiple Choice
What is your gender? (optional)
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q13
Multiple Choice
How do you mainly pay for these therapy sessions? (optional)
- Private/employer health insurance
- Public or government insurance
- Out of pocket
- Employee assistance program
- Prefer not to say
Q14
Message
Thank you for sharing your experience — this feedback directly shapes whether we keep offering flexible from-home sessions, expand in-person options, or build a hybrid model. Your responses are combined with others' and kept confidential.
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.
Why this template
What this template is built to do — we found no directly comparable template from other survey tools to review.
What sets it apart
- Includes a matrix and opinion-scale set that captures satisfaction, ease of scheduling, and agreement with specific home-therapy statements in one structured pass
- Uses a max-diff question to force trade-off prioritization (e.g., privacy vs. connection with therapist) rather than relying on a single ranked list
- Pairs a direct multiple-choice preference question (continue from home, hybrid, in-person) with an AI follow-up interview that adapts its probing to that stated preference, digging into the specific trade-offs behind it
- Captures practical barriers (what's gotten in the way of video/phone sessions) alongside payment method and demographics, giving practices context for why preferences differ across client segments
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.