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Family Therapy Intake and Concerns Assessment

Gathers a new family therapy client's presenting concerns, family structure, history, and goals before the first session, with an AI follow-up that explores the core relational conflict in the client's own words. Built for family and marriage therapists to speed up intake and arrive at session one with real context.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

15 questions · ~8 min
Q01
Message

Welcome, and thank you for taking this step. Before your first session, we'd like to understand a bit about your family and what brings you in. This takes about 6-8 minutes, and everything you share is confidential and only used by your therapist.

Q02
Short TextRequired

Who is completing this intake form (your name and relationship to the family, e.g. 'parent', 'adult child')?

Q03
Multiple ChoiceRequired

Who will be attending family therapy sessions?

  • Both/all parents or guardians
  • One parent or guardian
  • Children or teens in the home
  • Siblings
  • Extended family (grandparents, etc.)
  • Partner/spouse
Q04
Long TextRequired

In your own words, what is the main reason your family is seeking therapy right now?

Q05
Multiple ChoiceRequired

Which areas is your family currently struggling with?

  • Communication and conflict
  • Parenting disagreements
  • A recent major change (divorce, move, loss, illness)
  • A child or teen's behavior or mental health
  • Substance use in the family
  • Financial stress
  • Blended family or step-family adjustment
  • Trust or infidelity
Q06
Opinion ScaleRequired

In the last 30 days, how often has conflict in your family disrupted daily life (meals, sleep, work, or school)?

Scale: 0 – 10
Min:Never disruptedMax:Disrupted constantly
Q07
MatrixRequired

How would you rate the current state of these areas in your family?

5 rows × 5 columns
  • Communication between family members
  • Trust and honesty
  • Ability to resolve disagreements
  • Emotional closeness
  • Consistency in parenting or household rules
Columns: Very poor · Poor · Fair · Good · Very good
Q08
Multiple ChoiceRequired

Has your family received counseling or therapy together before?

  • Yes, and it helped
  • Yes, but it didn't help much
  • No, this is our first time
Q09
Multiple ChoiceRequired

Are there any safety concerns we should know about before your first session (e.g. domestic violence, self-harm risk, active substance abuse)?

  • Physical violence or fear of harm
  • Thoughts of self-harm or suicide by a family member
  • Active substance abuse affecting safety
  • Child safety concern
Q10
AI Interview

Gently explore the core relational conflict the respondent named as the main reason for seeking therapy: ask for a recent specific example of when it happened, who was involved, what each person did or said, and how it typically ends. If they flagged any safety concern, prioritize understanding current safety and whether they need immediate support rather than probing the conflict further, and note this clearly for the therapist. If their answer is vague or minimizing, ask what a hard week for this family actually looks like.

Q11
Long Text

What would you consider a meaningful sign of progress after a few months of family therapy?

Q12
Short Text

Is there anything about your family's culture, faith, or background you'd like your therapist to understand from the start?

Q13
Dropdown

What is the approximate age range of the youngest child involved in therapy, if any?

  • No children involved
  • Under 5
  • 5-9
  • 10-13
  • 14-17
  • 18 or older
Q14
Multiple Choice

Household income range (optional, helps us discuss fee options if relevant)

  • Under $30,000
  • $30,000-$59,999
  • $60,000-$99,999
  • $100,000 or more
  • Prefer not to say
Q15
Message

Thank you for sharing this with us — it takes courage to reach out. Your therapist will review these answers before your first session so you can spend that time talking about what matters most, not filling out forms.

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

  • Captures presenting concerns, family structure, history, and goals in the client's own words before session one, so therapists arrive with real context
  • Includes an AI follow-up interview that gently explores the core relational conflict the client named as their main reason for seeking therapy, going beyond a static field
  • Covers practical intake needs therapists need before a first session — who's attending, prior counseling history, safety concerns, and a matrix rating current family functioning across key areas
  • Closes with a warm, transparent chat message setting expectations for how the shared information will be used in the first session

Jotform

Family Therapy Intake Form Template

A ready-to-field static intake form builder template covering standard family therapy intake fields like contact info and presenting concerns. It's a form-builder product, so customization is flexible, but every respondent sees the same fixed question set. No mechanism exists to probe deeper into a stated concern.

What it does well

  • Fielding-ready template usable immediately
  • Familiar drag-and-drop form builder for easy customization
  • Likely supports file uploads and e-signature for intake paperwork

Where it falls short

  • Static form with no adaptive follow-up to explore the client's stated concerns further
  • No AI-driven quality scoring of responses
  • No voice interview option for clients who prefer speaking over typing

Typeform

Family Therapy Intake Form Template

A polished, conversational one-question-at-a-time intake template well-suited to therapy's sensitive tone. It relies on branching logic rather than genuine AI-driven follow-up, so it can route respondents down predefined paths but cannot dynamically generate a new question based on what a client actually writes.

What it does well

  • Clean, conversational UI that suits a sensitive intake context
  • Logic-based branching to skip/show questions based on prior answers
  • Strong mobile-friendly design and completion experience

Where it falls short

  • No adaptive AI follow-up that responds to the client's own words about their core conflict
  • No automated per-response quality scoring or auto-generated clinical-context reports
  • No optional voice AI interview mode for clients who prefer talking

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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