Q01
Message
All templatesIndustry-Specific
Pre-Visit Psychiatric Evaluation Intake Questionnaire
A pre-appointment intake for mental health clinics that captures a patient's presenting concern, symptom frequency across common domains, functional impact, safety status, and treatment history before a first psychiatric visit. An AI follow-up interview reconstructs concrete recent examples behind the ratings and checks in sensitively on any safety responses. Not a substitute for crisis assessment.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
Long TextRequired
In your own words, what's the main concern that brought you to seek this evaluation?
Q03
Multiple ChoiceRequired
How long have you been dealing with this concern?
- Less than 2 weeks
- 2 weeks to 1 month
- 1 to 6 months
- 6 to 12 months
- More than a year
- This is a recurring issue I've dealt with before
Q04
MatrixRequired
Over the past two weeks, how often have you experienced each of the following?
8 rows × 4 columns
- Low mood or sadness
- Feeling anxious or on edge
- Irritability or anger
- Trouble sleeping
- Appetite or weight changes
- +3 more
Columns: Not at all · Several days · More than half the days · Nearly every day
Q05
Opinion ScaleRequired
How much have these concerns interfered with your daily life (work, school, relationships, or self-care) in the last two weeks?
Scale: 0 – 10
Min:Not at allMax:Completely unable to function
Q06
Multiple ChoiceRequired
In the past two weeks, how often have you had thoughts that you would be better off dead or of hurting yourself in some way?
- Not at all
- Several days
- More than half the days
- Nearly every day
Q07
Multiple Choice
Are you currently taking any medication prescribed for a mental health condition?
- Yes
- No
- Not sure
Q08
Multiple Choice
Which best describes your prior mental health treatment history?
- No previous treatment
- Outpatient therapy only
- Medication only
- Both therapy and medication
- Inpatient or crisis-level care
- Not sure / prefer not to specify
Q09
Multiple Choice
What are you hoping this evaluation leads to? Select all that apply.
- A clearer understanding of what's going on
- Medication options
- Therapy or coping strategies
- Support during a difficult life event
- A formal diagnosis
Q10
AI Interview
Explore the respondent's main presenting concern in depth: when it started, what triggered or worsened it, and what has changed in the last two weeks. If they indicated any thoughts of self-harm as occurring more than 'not at all', gently ask how they are keeping safe right now and clearly note that if they are in immediate danger they should contact emergency services or a crisis line rather than continue. Anchor follow-up on one or two concrete recent examples (a specific day, interaction, or event) rather than general feelings, and note any gap between how they described the problem in their own words and how they rated its severity.
Q11
Multiple Choice
What is your age range? (optional, for clinical context)
- Under 18
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Q12
Multiple Choice
What is your gender identity? (optional, for clinical context)
- Woman
- Man
- Non-binary
- Prefer not to say
Q13
Multiple Choice
Which best describes your current living situation?
- Live alone
- Live with partner or spouse
- Live with family
- Live with roommates
- Other
- Prefer not to say
Q14
Message
Thank you for sharing this — your responses will be reviewed by your provider before your appointment to help focus your time together. If anything changes before then, especially around your safety, please reach out to a crisis line or emergency services right away.
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 concern, symptom frequency across common domains, functional impact, safety status, and treatment history in one structured pre-visit flow
- Includes an AI follow-up interview that reconstructs concrete recent examples behind ratings and checks in sensitively on any safety-related responses, rather than leaving flagged answers unexplored
- Uses transparent prompts and automated per-response quality scoring so clinicians receive a fuller, more consistent picture before the first visit
- Closes with a clear message explaining that responses will be reviewed by the provider before the appointment, setting appropriate expectations for a clinical (not crisis) context
Jotform
Psychiatric Evaluation Form TemplateA static, fielding-ready form template covering standard psychiatric evaluation fields that clinics can customize with Jotform's form builder. It's a fixed questionnaire rather than an interview, so all follow-up and clarification has to be done manually by staff. Good for quick deployment but offers no built-in mechanism to probe deeper on any given answer.
What it does well
- Ready-to-use template that can be deployed quickly without building from scratch
- Customizable form fields and layout via Jotform's drag-and-drop builder
- Likely integrates with Jotform's broader form ecosystem (e-signatures, conditional logic, notifications)
Where it falls short
- No adaptive AI follow-up interview to reconstruct concrete examples behind answers
- No voice AI interview option
- No automated per-response quality scoring or auto-generated clinical-ready reports
Typeform
Psychiatric Evaluation Form TemplateA conversational-style static form template for psychiatric evaluation intake, built on Typeform's one-question-at-a-time interface. It offers a smoother respondent experience than a traditional form but still relies on fixed questions with no dynamic probing of responses. Safety-related answers would need manual clinical review with no automated sensitive check-in built in.
What it does well
- Polished, respondent-friendly conversational UI that may improve completion rates
- Easy to customize question wording and branding within Typeform
- Supports basic logic branching between questions
Where it falls short
- No adaptive AI follow-up interview or voice AI interview to explore concerns in depth
- No automated sensitive check-in on safety-related responses
- No automated per-response quality scoring or auto-generated reports for clinicians
Frequently asked questions
What questions are in the “Pre-Visit Psychiatric Evaluation Intake Questionnaire” template?
The template includes 14 ready-to-use questions, starting with: “Thanks for taking a few minutes before your appointment. These questions help your provider understand what's going on b…” · “In your own words, what's the main concern that brought you to seek this evaluation?” · “How long have you been dealing with this concern?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 14 questions in about 7 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
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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