Healthcare and wellness

Counselling intake

Follow-ups depend on earlier answers, and a crisis warning shows when someone says they need help now. Free to use with FillKite.

Live demo

Counselling intake

Fill it in and press the button to see how it behaves. Nothing you type is saved or sent.

What is in this form

First name (required)
Email (required)
What brings you here? (required)
Tell us what else
Have you seen a counsellor before? (required)
What helped, and what did not?
How would you like to meet? (required)
Your city (required)
Do you need help right now?

How the conditional logic works

This form shows or hides fields as people answer, so everyone sees only what matters to them.

“Tell us what else” appears only when “What brings you here?” includes “Something else”.
“What helped, and what did not?” appears only when “Have you seen a counsellor before?” is “Yes”.
“Your city” appears only when “How would you like to meet?” is “In person”.
A notice appears only when “Do you need help right now?” is “Yes”.

Use it on your site

Install FillKite free from WordPress.org.
Download this form with the button above.
Go to FillKite → Import → From a FillKite file, choose the file and import it.

Questions

About this form

Is the counselling intake form free?

Yes. It works with the free FillKite plugin, and you can download it and change it as you like.

Is anything I type saved?

No. This demo runs in test mode: FillKite checks your answers like a real form, but nothing is saved and no email is sent.

How do I use this form on my site?

Install FillKite, download the form with the button on this page, then go to FillKite → Import → From a FillKite file and choose the file. After importing, open it in the builder, change anything you like and add it to a page.

Does this form use conditional logic?

Yes. 4 fields or notices show only when earlier answers call for it. “Tell us what else” appears only when “What brings you here?” includes “Something else”.

What fields does it have?

It has 9 fields: First name, Email, What brings you here?, Tell us what else, Have you seen a counsellor before?, What helped, and what did not?, How would you like to meet?, Your city and more.

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