Q01
Message
All templatesIndustry-Specific
Psychiatric Intake and Symptom Screening Survey
A pre-appointment intake for mental health practices that captures presenting concerns, symptom frequency over the last two weeks, treatment history, and safety screening before the first visit — with an AI follow-up interview that reconstructs the story behind the symptoms (onset, triggers, what's changed) so clinicians walk in with context instead of a blank checklist.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
ConsentRequired
Before we start, please review how your responses will be used.
Q03
Multiple ChoiceRequired
What is bringing you in for care right now? Select all that apply.
- Anxiety or excessive worry
- Low mood or depression
- Sleep problems
- Relationship or family stress
- Substance use
- Past trauma or a specific event
- Work or school stress
- Grief or loss
Q04
MatrixRequired
Over the last 2 weeks, how often have you been bothered by each of the following?
6 rows × 4 columns
- Trouble falling or staying asleep
- Feeling down, low, or hopeless
- Feeling anxious or on edge
- Irritability or being easily annoyed
- Trouble concentrating on tasks
- +1 more
Columns: Not at all · Several days · More than half the days · Nearly every day
Q05
Opinion ScaleRequired
How much have these difficulties gotten in the way of your work, relationships, or daily life recently?
Scale: 0 – 10
Min:Not at allMax:Completely unable to function
Q06
Multiple ChoiceRequired
What best describes your current involvement with mental health treatment?
- Currently in therapy
- Currently taking psychiatric medication
- Previously received treatment, not currently
- Never received treatment for this
- Prefer not to say
Q07
Long Text
In your own words, what's changed recently that made now feel like the right time to seek help?
Q08
AI Interview
Reconstruct the story behind the respondent's presenting concern and symptom pattern: when it started, what triggered or worsened it, what they've already tried on their own, and how it's specifically affecting their daily functioning. If they flagged multiple concerns, ask which one feels most urgent right now. If their symptom answers suggest high frequency or severe functional impact, gently and clearly probe for safety and immediate risk, and note that this should be flagged for clinician review rather than resolved in this interview.
Q09
Multiple ChoiceRequired
In the last 2 weeks, have you had any thoughts of harming yourself or someone else?
- Never
- Rarely
- Sometimes
- Often
- Yes, and I have a plan
Q10
Ranking
Rank what you most want out of treatment, from most to least important.
- Feeling less anxious or worried
- Improving my mood
- Sleeping better
- Better coping tools for stress
- Repairing a relationship
- Understanding myself better
- Reducing or stopping substance use
Drag to rank
Q11
Multiple Choice
Which format of care are you most interested in right now?
- Individual talk therapy
- Medication management
- Group therapy
- A combination of therapy and medication
- Not sure yet
Q12
Multiple Choice
What is your age range?
- Under 18
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Q13
Dropdown
What is your gender identity?
- Woman
- Man
- Non-binary
- Another identity
- Prefer not to say
Q14
Message
Thank you for sharing this — it takes courage. Your responses will be reviewed by your care team before your appointment so your first session can start from where you actually are.
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
- Includes a symptom-frequency matrix covering the last two weeks plus an impairment rating, paired with an AI follow-up interview that reconstructs onset, triggers, and what's changed — clinicians get narrative context, not just checkbox scores.
- Built-in safety screening question on thoughts of self-harm or harm to others, plus an upfront consent step and a closing message clarifying that responses are reviewed by a clinician before the visit.
- Captures treatment history, preferred care format, and a ranked list of what the patient wants out of treatment, combining structured intake data with open-ended qualitative context (in the patient's own words).
- AI follow-up prompts are transparent and each response is auto-scored for quality, with an auto-generated report for the clinician — capabilities static form builders don't offer.
Jotform
Psychiatric Intake Form TemplateA ready-to-field, psychiatric-specific intake form covering history and presenting concerns, with Jotform's usual form-builder flexibility (fields, e-signature, integrations). It's a static document-style form rather than a conversational interview, so all follow-up depends on pre-built fields, not the patient's actual answers.
What it does well
- Purpose-built for psychiatric intake rather than a generic template
- Extensive field types and customization typical of Jotform's builder
- Likely supports e-signature and HIPAA-related form options common on the platform
Where it falls short
- Static form with no adaptive AI follow-up questioning
- No mechanism to reconstruct the story behind symptoms beyond fixed fields
- No automated per-response quality scoring or auto-generated clinician report
Typeform
Psychiatric Intake FormA conversational, one-question-at-a-time psychiatric intake template that's pleasant to fill out on mobile, in Typeform's signature style. Branching logic can tailor which questions appear, but there's no true adaptive interview that probes deeper based on what a patient actually writes.
What it does well
- Clean, conversational single-question UI likely to improve completion rates
- Mobile-friendly presentation suited to pre-appointment intake
- Supports logic jumps to skip/show questions based on prior answers
Where it falls short
- Logic branching is rule-based, not an AI interview that adapts to free-text content
- No voice interview option or guided screen-share tasks
- No transparent prompt library or automated quality scoring on responses
SurveyMonkey
Client Intake Form TemplateA general-purpose client intake template, not specific to psychiatry or mental health, that would need substantial customization (symptom checklists, safety screening) before it's appropriate for a psychiatric practice. It benefits from SurveyMonkey's broad survey-logic and reporting tools but isn't a clinical-intake template out of the box.
What it does well
- Backed by SurveyMonkey's mature survey logic and analytics dashboard
- Easy to distribute across email/web/link channels
- Familiar builder that non-clinical staff can edit quickly
Where it falls short
- Generic client intake, not tailored to psychiatric symptom screening or safety questions
- Static question set with no adaptive AI follow-up interview
- No option for voice AI interviews or guided screen-share tasks
SurveySparrow
Sample client intake form templateA generic business client intake template with a conversational chat-style form experience, not built for psychiatric or clinical use, so symptom screening and safety questions would have to be added from scratch. Useful as a starting shell for a chat-style form but not a fielding-ready mental health intake.
What it does well
- Chat-style conversational UI similar in feel to a guided interview
- General intake structure could be adapted for various business/service contexts
- Likely easy to theme and re-brand for a practice's intake page
Where it falls short
- Not designed for psychiatric symptom frequency or safety screening
- No adaptive AI questioning — the chat-style flow is scripted, not responsive to content
- No automated scoring, transparent AI prompts, or auto-generated clinical report
Frequently asked questions
What questions are in the “Psychiatric Intake and Symptom Screening Survey” template?
The template includes 14 ready-to-use questions, starting with: “Welcome — thanks for taking a few minutes before your appointment. Your responses are completely confidential and anonym…” · “Before we start, please review how your responses will be used.” · “What is bringing you in for care right now? Select all that apply.”. 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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