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Design surveys, run conversational interviews, and get clear insights. Every response stays encrypted.

AI Survey CreationEffortlessly create high-quality, unbiased surveys with AI-powered tools that save time and reduce cost.AI Survey AnalysisUnlock instant, detailed insights from survey data. AI-powered approach, providing thematic and systematic analysis, anomaly detection, and more.Survey MCPConnect BlockSurvey to Claude, Claude Code, and ChatGPT to create, edit, and publish surveys without leaving your AI assistant.Conversational AI SurveysExperience natural conversations with BlockSurvey's AI-driven survey platform. Create dynamic, personalized dialogues that adapt to each respondent, revealing deeper insights.AI Thematic AnalysisSave hours by automating your thematic analysis process. Quickly identify common patterns and insights from qualitative data.AI Sentiment AnalysisLeverage the power of AI to seamlessly identify sentiment polarity in your qualitative research.AI Adaptive QuestioningGet smarter open-ended responses through AI-powered adaptive follow-up questions in your survey.AI Sample Responses GeneratorGet smarter open-ended responses through AI-powered adaptive follow-up questions in your survey.AI Survey MigrationGet smarter open-ended responses through AI-powered adaptive follow-up questions in your survey.Generate Options with AIBoost engagement with AI-crafted choices that make answering easier and more intuitive.Rephrase with AIRefine the question and description wording in your survey with AI-powered rephrasing for better clarity and tone.Data Encoding with AITurn open-ended responses into categorized insights with AI.AI Survey OptimizationImprove your survey quality effortlessly with AI-powered optimization—spot bias, refine question clarity, and increase completion rates.

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Rank OrderRespondents drag and arrange a list of options in their preferred order.Matrix TableAsk multiple related questions in a single grid with shared answer choices.Constant SumRespondents distribute a fixed total (like 100 points) across multiple options.File UploadCollect documents, images, or other files directly from respondents.Net Promoter Score (NPS)Measure how likely respondents are to recommend you on a 0-10 scale.Social VerificationVerify a respondent's identity by linking their social media account.Loop QuestionRepeat a set of questions automatically for each item in a list.Group QuestionBundle related questions together under a single heading or section.A/B Testing Show different versions of a question to different respondents and compare responses.

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Market ResearchBoost your market research with AI-driven surveys that enhance response rates, ensure data privacy, support white label branding, and offer advanced analysis tools.Institutional ResearchCreate AI-powered surveys & assessments to understand your institution's goals for students, faculty & advisors.HealthcareCollect patient feedback securely with HIPAA compliance and end-to-end encryption, earn patient trust.B2B SaaSReplace guesswork with real signals from the buyers who matter, make every decision with confidence.B2C SaaSCollect honest product feedback from your SaaS users, build what they actually need, not what you assume.Healthcare SaaSHIPAA-compliant product feedback and clinical user research, build products clinicians actually want.Mental HealthSecurely conduct mental health assessments with end-to-end encryption, ensuring privacy and comfort for respondents using ready-to-use, privacy-focused templates.Women's HealthcareRun private, encrypted surveys for Femtech and women's health research, get the data women actually share.Digital HealthcarePower your digital health product with AI conversational surveys, collect health data users trust you with.Preventive HealthcareDeploy health risk assessments across your population, catch risks before they become costs.ActivismRun Activism surveys securely with this trusted data collection platform, where Onion Routing is enabled to protect respondent identity.Non-ProfitRun Privacy-Focused Surveys for validation & impact of your Non-Profit proposal, all at a special discounted price for Non-Profit Organizations.

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Learn the craft

Guides, templates and playbooks to help you run better research.

Use CasesThe Use Cases highlighting various applications of BlockSurvey for different business needs, including customer churn, employee exit, product market fit, and uninstall feedback surveys.AI GuidesThe AI Guides page provides resources on artificial intelligence, covering machine learning, natural language processing, and computer vision to help users innovate and stay updated.Survey GuidesThe BlockSurvey Guides page provides comprehensive resources on survey design, data security, and market research techniques for creating effective and secure surveys.PlaybooksStrategies and guides for capturing qualified leads using surveys across various niches.WebinarsGain Valuable Insights from top industry experts with our comprehensive webinar series.PodcastWatch our podcast episodes on survey design, data privacy, and research best practices.WhitepaperBeyond the Response Rate — qualitative research with 15 IR professionals at 15 U.S. institutions.

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Counseling Intake Form

Gather essential client details, mental health history, and therapy goals with this counseling intake form. Ideal for counselors, therapists, and mental health professionals in any practice setting.

3 minutes to complete

Eligibility

To complete the Counseling Intake Form, individuals must be at least 18 years old, willing to participate in counseling sessions, and able to provide accurate and honest information about their mental health history and current concerns.

Questions for Counseling Intake Form

Questions for Counseling Intake Form

1.

Contact Details

2.

Are you currently employed or in school?

The answer should be a single choice:

Yes
No

3.

Where are you currently employed?

The answer should be a text input.

4.

Primary Reason for Seeking Counseling

The answer should be a single choice:

Stress management
Relationship issues
Anxiety or depression
Career guidance
Grief and loss
Personal development
Family conflicts
Trauma or abuse recovery
Substance abuse
Self-esteem improvement

5.

How long have you been experiencing this concern?

The answer should be a single choice:

Less than a week
1 to 4 weeks
1 to 3 months
3 to 6 months
More than 6 months

6.

Have you seen a counselor or therapist before?

The answer should be a single choice:

Yes
No

7.

When was your recent session?

The answer should be a text input.

8.

Are you currently taking any medications?

The answer should be a single choice:

Yes
No

9.

Please list your Medications:

The answer should be a text input.

10.

Do you have any medical conditions or allergies?

The answer should be a single choice:

Yes
No

11.

If yes, please explain:

The answer should be a text input.

12.

How would you rate your current stress level?

The answer should be a rating.

13.

Anything else you’d like your counselor to know?

The answer should be a text input.

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Collect essential client information, including mental health history, presenting concerns, and treatment goals. Designed for psychologists, therapists, and clinical practices offering psychotherapy. Helps streamline assessment and prepare for effective, personalized care from the very first session.

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Gather essential client details, mental health history, and therapy goals with this counseling intake form. Ideal for counselors, therapists, and mental health professionals in any practice setting.

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Collect essential client information, mental health history, and therapy goals with this easy-to-use intake form. Perfect for therapists, counselors, and mental health professionals in private or clinical practice.

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Discover the latest findings on youth mental health with this comprehensive survey. Explore the statistics, trends, and insights that shed light on the challenges facing young people today. Gain valuable knowledge that can help support and advocate for the well-being of our youth. Stay informed and make a difference in the mental health landscape.

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Over the last two weeks, how often have you been bothered by any of the following problems?

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Over the last 2 weeks, how often have you been bothered by the following problems?

FAQs on Counseling Intake Form

: The form gives your counselor important background—personal history, presenting concerns, and therapy goals—so your first session can focus on meaningful conversation rather than basic data gathering.
: The form typically asks for personal details, mental health history, current challenges, medications, and what you hope to achieve through counseling.
: No, you usually only need to complete the intake form once before your first session. Updates may be requested if your situation changes.

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What people say

Join 500+ happy customers worldwide who are already using our amazing product.

Beyond Surveys—A Truly Multi-Purpose Tool

This platform goes far beyond basic surveys. I’ve used it for lead generation, landing page enrichment, and even embedded videos. Everything’s easy to use, well documented, and super flexible—whether you're building forms, quizzes, or something more advanced.

Martin G.Créateur de la Méthode Rashōmon

UI/UX is great and fast API processing

I think BlockSurvey is good for short and long surveys. What I find the best is the fact that there are so many templates I can use and customize.

Ankit M.AI Analyst Team Lead

AI form builder for top security and data privacy

Uses end-to-end encryption technology that allows users to create survey forms where data is secure and private. UI looks very beautiful.

Lou F.Creative Visionary

Nothing Like It — BlockSurvey Is in a League of Its Own!

From end-to-end encryption-level security and AI-generated questions to powerful logic flows and white-label domains, BlockSurvey has it all. It’s secure, innovative, and packed with features like calculations, templates, and in-app analytics. I use it to create personalized assessments for leadership training—nothing else compares.

Kim B.Founder/ President - International Leadership Trainer

Survey and Forms for Privacy and Security

BlockSurvey puts privacy and security above anything else. The use of end-to-end encryption is not a gimmick as in many products; it's a core feature enabling privacy and security. The survey building tools are impeccable. I've used numerous SaaS survey tools, and nothing comes close.

Trevor L.Chief Information Security Officer (CISO)

Big fan of BlockSurvey and what Wilson and the team are doing. BlockSurvey was the end-to-end encrypted product I signed up for and I love the UI, privacy, responsiveness, and transparency behind the platform. Great job all 'round and awesome to see it keep evolving.

James Longley@jameslongley

Unmatched Security & Stunning Response Rates

Few tools combine data confidentiality and form aesthetics like this one. The conversational design improved my response rate by 43%, and the webhook integrations made syncing to our CRM effortless. I also love how responsive and community-driven the support team is.

Kris R.Group Automation Manager

Powerful custom surveys

Creating surveys with BlockSurvey has been a breeze. The drag-and-drop interface is intuitive, and we’re able to collect data anonymously and securely—without intermediaries. It’s interactive, friendly, and encourages high participation while protecting user privacy. The reports are solid, and we’ve used it confidently for internal and external feedback.

Liz D.IT Support Specialist

Private, Beautiful Surveys That Build Trust

For our NGO, data privacy is everything—and this platform nails it. It keeps personal info fully protected while letting us design beautiful, chat-like surveys that increase engagement. Team collaboration features sealed the deal.

Luis Noel D.Director Comercial

Want to create secure online forms and surveys?Join BlockSurvey.

About Us

BlockSurvey is a privacy-focused platform for collecting data through forms, surveys, assessments, and quizzes. The data collection is end-to-end encrypted, and it ensures complete privacy of your audience from Big Tech. With an array of ready to use templates, it is tailored for the needs of businesses and individuals from Web 3, HR, Mental Health, Sexual Health, Activism and many sensitive areas where data collection needs protection.