Mental Health Survey

Use this free Mental Health Survey template as is for your practice. Or, use it as inspiration to build your own! Issuing a mental health survey to your new patients before they start their first appointment will set the groundwork for discussion!

By Harriet Murray on Aug 2, 2025.

Fact Checked by Ericka Pingol.

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What are Mental Health Surveys?

Over the years, mental health has been treated just as seriously as physical health, given that a person’s mental well-being may affect even the person’s physical health down the line. A person’s mental well-being may also affect various aspects of their life, such as making choices, interacting with the people around them, and dealing with stressful events.

were developed to do numerous things, such as knowing the most common mental health disorders within a specific community, city, state, country, or even the whole world! Another thing that surveys can do is determine the reasons behind a person’s mental illness.

Here at Carepatron, we have a Mental Health Survey template that was created as a pre-first appointment survey for a patient. A person’s mental health can be a sensitive subject, and patients may find it difficult to talk about. This survey template will set the grounds for discussion once they start seeing you for mental health therapy/psychiatry.

Mental Health Survey Template

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How to use this Mental Health Survey template

Issue this to your patient before their first appointment with you.

Given that this mental health survey template was designed specifically for screening before a first appointment, you (or your assistant/nurse) should issue this to them as soon as an appointment has been scheduled.

If they scheduled in person, give it to them on the spot and have them accomplish it immediately. If they scheduled online, send it to them via email. It will be even better if you have automated the form to be immediately sent to the client after they schedule a booking.

Patients simply need to answer the survey.

The survey is straightforward to answer. It’s a mixture of multiple-choice and sentence questionnaires.

First is the general information. They just need to write their full name, their date of birth, tick their gender (male, female, or non-binary), indicate the date of their birth, indicate the date of their appointment, indicate the current date, and their relationship status.

Second, they need to answer some questions. Some are multiple-choice questions that vary in terms of answers. Some are even simple YES or NO questions. And there are those that ask them to elaborate. Here are the following questions they need to answer:

How would you rate your overall mental health state right now? (multiple choice)
Do you currently have any concerns regarding your mental health (e.g. you have bouts with anxiety, depression, stress, etc.)? (Yes or No)
During the past month or quarter, did you encounter any problems with your daily life and school/work caused by mental health issues like sadness, anxiety, depression, etc.? (Yes or No)
If yes, would you mind describing these problems? Be as descriptive as you can possibly be. Write N/A if you answered No. (Sentence answer)
During the past month or quarter, has your mental health affected your performance in school/work? (Multiple choice)
During the past month or quarter, has your mental health affected your dietary habits? (Yes or No)
If so, how has it affected your dietary habits? Be as descriptive as you possibly can be. (Sentence answer)
Do you drink and/or smoke? (Multiple choice)
Has your mental health affected your routine? (Yes or No)
If so, how has it affected your routine? Be as descriptive as you possibly can be. (Sentence answer)
Have you felt any extended periods of feeling down because of your mental health? (Yes or No)
If so, what was the longest period of your feeling down in the past month or quarter? (Multiple choice)
Has your mental health affected any of your relationships in the past month or quarter? (Yes or No)
How often did it affect your relationships in the past month or quarter? (Multiple choice)
Can you describe how it affected at least one of your relationships? This is optional. (Sentence answer)
Are you content with your relationships? (Sentence answer)
Did anyone support you with your mental health? Tick all that apply. (checklist)
When was the last time you felt happy about yourself and/or had a positive outlook on life? (Sentence answer)
Did you change jobs recently? (Yes or No)
Did you change jobs/leave your work because of your mental health? (Yes or No)
Anything else you want to share regarding your mental health? (Sentence answer)

Determine what to discuss for your first session.

Once you receive a fully-accomplished survey, it’s best to sit down and remember their answers, especially the sentence answers. These should help you frame and structure your first appointment. Depending on how that discussion goes, you might have to issue worksheets or assessments to further analyze their situation before developing a care plan.

You can use the Care Plan Template to develop comprehensive and individualized care strategies for your patients. This template helps in outlining goals, interventions, and expected outcomes, ensuring a structured approach to patient care.

When would you typically use this Mental Health Survey template?

This template was designed to be answered as soon as a first appointment has been scheduled.

If they scheduled the appointment in person, you or your assistant/nurse should hand a copy of this to the patient for them to answer on the spot.

If they scheduled the appointment online through a registration form, ensure you have an automated response and function telling them to complete this survey and send it to you at least 1 day before their appointment. This is so you have ample time to prepare for a fruitful discussion.

Who can use this printable Mental Health Survey template?

The following healthcare practitioners can use this Mental Health Survey template for their respective practices:

(Clinical) psychologists
Psychiatrists
(Mental health) therapists
Counselors
The nurses and assistants of the practitioners mentioned above

Why are mental health surveys important to psychologists and adjacent practitioners?

As mentioned earlier, mental health surveys have the capability to help psychologists, psychiatrists, psychometricians, and other adjacent practitioners to do the following:

Determine the common mental health disorders within a specific community, city, state, country, or even the whole globe
Determine the possible root causes and factors that give rise to the different kinds of mental health problems

Besides those two, mental health surveys may also assess if mental health care is available in certain places and determine the various aspects of mental health care that can be improved.

What are the benefits of using this Mental Health Survey template?

You can totally use it for your practice!

Hey, we’re all about making things easy for you, so if you’re having a terrible time with creating your own pre-first appointment mental health survey template, you can totally use this template as is.

You can also use it as inspiration to make your own!

Of course, if you still want to create your own pre-first appointment mental health survey template, feel free to use this template as inspiration for when you develop the questions you want to ask your new patient.

It should help you frame the discussion for your first appointment with your patient.

The survey template was created to be answered and submitted before the scheduled appointment. The answers of your patient should help you frame and create the structure of the discussion you’ll have. This will make it easier to determine and better understand what is causing their problems with their mental health and how to proceed post-first appointment.

What is your patient exactly experiencing? Depression? Anxiety? Stress?

Do you need to hand out a worksheet or assessment to better understand the patient?

Do you need to diagnose the patient as soon as possible?

These are just some of the questions that might be answered by the end of the first appointment, and the answers to these will set the course for subsequent sessions and even the care plan you will develop down the line.

Commonly asked questions

The questions you must write should benefit you in the way that you are able to understand the patient in terms of what they are going through mental health-wise and if it is affecting other aspects of their life. If you’re having trouble with that, you can use our template for free! Or use it as inspiration to give you an idea as to what questions you should ask.

Because their answers should be able to give you the preliminary information you need as grounds for your first appointment. You can go straight to discussing the problem (if you are able to determine that based on their answers) during the appointment to get the ball rolling immediately.

That’s okay. You can use these questions during your first appointment to, hopefully, get them to talk. This might increase the number of subsequent sessions down the line, but the end goal is to help the patient so it shouldn’t matter if they didn’t answer it. Of course, it would be best for them to answer and submit it so you can set the course for your appointments immediately.

Just keep in mind that mental health is a touchy subject for most people, so you don’t want to put unnecessary stress on them through this survey. If they don’t answer it, don’t sweat it. Give them the time they need to open up. If it means increasing the number of sessions with you, so be it.