About this template
This Psychology Questionnaire template helps mental health professionals, counselors, and researchers gather comprehensive background information and psychological evaluations from patients or study participants. Designed to streamline the intake process, the form captures essential demographic details, family background, academic or work stress, lifestyle habits, and standardized symptom ratings.
Collecting this information securely and efficiently before a first session or as part of an ongoing clinical assessment allows practitioners to prepare effectively and focus valuable time on patient care. The template organizes complex clinical inquiries into clear, structured sections ranging from personal history to emotional well-being and daily functioning.
With Doc2Form, you can instantly convert this template into a fully functioning Google Form, customize questions to fit your specific clinical practice or research requirements, and share it securely with respondents for immediate completion.
Key features
- Streamline patient intake and psychological background checks.
- Organize comprehensive clinical inquiries into clear sections.
- Evaluate emotional well-being, stress levels, and lifestyle factors.
- Instantly ready to customize and deploy via Google Forms.
Use cases
Initial patient intake at a private psychology practice or counseling…
Initial patient intake at a private psychology practice or counseling center.
Academic research studies focusing on student stress and mental health.
Clinical psychology assessments and psychological well-being tracking.
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Age (Short answer)Enter your current age in years.
- Biological Sex (Multiple choice)Select your biological sex.
- Marital Status (Dropdown)Select your current marital or relationship status.
- Do you have children? (Short answer)Indicate whether you have children and how many.
- Were your parents divorced during your childhood? (Multiple choice)Select the option that applies to your upbringing.
- Have you experienced any family death in the last 12 months? (Multiple choice)Select yes if you have experienced the loss of a close family member recently.
- Have you experienced a recent romantic breakup? (Multiple choice)Indicate if you have gone through a significant separation or breakup recently.
- Exercise Frequency (Dropdown)How often do you engage in physical exercise or sports?
- Sadness Level (Linear scale)Rate your level of persistent sadness from 1 (None) to 5 (Severe).
- Future Discouragement Level (Linear scale)Rate how discouraged you feel about the future from 1 (Not at all) to 5 (Extremely).
- Loss of Satisfaction Level (Linear scale)Rate how much you have lost pleasure or satisfaction in things you usually enjoy.
- Irritability Level (Linear scale)Rate your general irritability or frustration level lately.
- Sleep Disturbance Level (Linear scale)Rate the severity of any sleep issues, such as difficulty falling asleep or staying asleep.
- Fatigue Level (Linear scale)Rate your daily level of physical and mental fatigue.
- Additional Comments or Concerns (Paragraph)Please share anything else you would like your practitioner to know before your appointment.
FAQ
How can I customize this psychology questionnaire for my practice?
Once you import this template into Doc2Form as a Google Form, you can easily add, remove, or modify questions directly within your Google Forms editor to match your specific clinical requirements.
Is this questionnaire template free to use?
Yes, this template is entirely free to convert into a Google Form and use for your patients or research participants.
Can I share this form securely with my patients?
Yes, Google Forms allows you to share your questionnaire via a direct link, email invitation, or embedded webpage so patients can complete it privately from any device.
How do I view and analyze the submitted responses?
All patient submissions are automatically organized in a connected Google Sheets spreadsheet, making it easy to review individual assessments or analyze trends securely.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.