Lesson 4 - Following Structured Forms and Questionnaires
1. Lesson Overview
Assistant practitioners may support patients and families to complete forms that they might otherwise complete independently.
The practitioner’s role is to present each question clearly and record the answer selected or provided by the patient or family. They must follow the approved form without adding their own clinical questions or changing the meaning of the items.
Some questionnaires use fixed wording, response options and scoring rules. Small changes in how a question is asked may influence the answer. The practitioner must therefore understand the instructions for each form before using it.
The assistant practitioner does not interpret questionnaire results or decide whether a score supports a diagnosis.
Suggested duration: 60 minutes
Delivery method: Self-directed learning followed by supervised form practice
Practical requirement: Accurate completion of an approved WMI Psychiatry form using a fictional case
2. Learning Outcomes
By the end of this lesson learners should be able to:
Explain the purpose of structured forms and questionnaires.
Distinguish between a questionnaire and a clinical assessment.
Follow the wording, order and response options of an approved form.
Identify who should provide the answers.
Apply the correct timeframe when asking questions.
Clarify questions without leading the respondent.
Record uncertain, missing or conflicting information accurately.
Recognise when a form must not be scored or interpreted by an assistant practitioner.
Complete a quality check before submitting the form.
Identify situations requiring advice from a supervisor.
3. The Lecture
Why structured forms are used
Structured forms help services collect information consistently.
They may gather information about:
Current symptoms.
Childhood experiences.
Development.
Education.
Employment.
Family life.
Physical health.
Mental health.
Sleep.
Medication.
Risk.
Functional difficulties.
Strengths and support needs.
A structured form ensures that the same general areas are considered for each patient.
A questionnaire may also use a fixed set of questions and response options. The answers may produce a score that is reviewed by the clinical team.
Questionnaires can contribute useful information. They do not make a diagnosis by themselves.
The assistant practitioner’s role
When supporting completion of a form the practitioner should:
Use the approved version.
Follow the instructions.
Explain the purpose of the form.
Confirm who should answer.
Read each question clearly.
Use the stated timeframe.
Present all relevant response options.
Clarify wording when needed.
Record the respondent’s answer.
Record examples when requested.
Identify unanswered or incomplete items.
Escalate concerning information.
Submit the form for clinical review.
The practitioner should not:
Choose an answer for the respondent.
Change an answer because it appears inconsistent.
Suggest which answer is most appropriate.
Add a diagnosis.
Change the wording in a way that alters the meaning.
Remove items that feel repetitive.
Interpret a score.
Tell the person whether they have passed or failed.
State that the result confirms or excludes a condition.
Use a form that they have not been trained or authorised to use.
Different types of forms
Not all forms should be used in the same way.
General information forms
These collect factual or descriptive information. The practitioner may usually explain the wording in plain language and ask neutral questions for clarification.
Examples may include:
Family background.
Developmental history.
Education history.
Current support.
Physical health.
Medication history.
Everyday functioning.
Screening questionnaires
These use set questions to identify whether further clinical exploration may be helpful.
The practitioner should usually preserve:
The original wording.
The order of questions.
The stated timeframe.
The available response options.
The respondent’s selected answer.
A screening result does not provide a diagnosis.
Standardised questionnaires
These have specific administration and scoring instructions. Their usefulness may depend on the form being administered consistently.
The practitioner should only administer a standardised questionnaire if:
WMI Psychiatry has authorised its use.
The practitioner has received the correct instructions.
The form is suitable for the patient and respondent.
The practitioner has been assessed as competent.
Any qualification or licensing requirements have been met.
The practitioner should not alter a standardised questionnaire unless the official instructions allow this.
Clinician-rated assessments
Some assessment tools require clinical knowledge and professional judgement. These are not suitable for basic information gathering.
The assistant practitioner must not complete a clinician-rated assessment unless this is specifically within their role and they have received appropriate training, supervision and authorisation.
If uncertain the practitioner should ask the supervising clinician before using the form.
Using the correct version
Before beginning the practitioner should check:
The title of the form.
The version or review date if shown.
Whether it is for a child or adult.
Whether it is for self-report or informant report.
Whether it applies to the correct assessment pathway.
Whether the whole form is present.
Whether any pages or sections are missing.
Whether there are separate instructions.
Whether the form is licensed or restricted.
Whether it is approved for use by WMI Psychiatry.
The practitioner should not download a similar form from the internet when the approved version cannot be found.
They should contact their supervisor if the correct form is unavailable.
Identifying the respondent
The respondent is the person providing the answers.
This may be:
The patient.
A mother.
A father.
Another person with parental responsibility.
A carer.
A partner.
A teacher.
Another person who knows the patient well.
The practitioner should confirm that the form is intended for that type of respondent.
A parent-report questionnaire should not be completed as a self-report questionnaire unless the instructions allow this.
The practitioner should record:
The respondent’s name.
Their relationship to the patient.
Whether the patient was present.
Whether anyone else contributed.
Whether the respondent needed help understanding or completing the form.
Whether an interpreter was used.
If two people provide answers together this should be recorded. If they disagree the practitioner should not combine their answers without clarification.
Explaining the form
Before beginning the practitioner should give a brief explanation.
For example:
“This form asks about a range of behaviours and experiences. I will read each question and the available answers. Please choose the answer that best reflects your experience. If a question is unclear I can explain what it is asking. I cannot choose an answer for you or interpret the final result.”
The practitioner should also explain:
The timeframe used by the form.
Whether every question should be answered.
Whether examples are required.
That the respondent can say if they are unsure.
That concerning information may need to be shared with a clinician promptly.
That the clinician will review the completed form.
Following the correct timeframe
Questionnaires may ask about different periods.
Examples include:
During the past two weeks.
During the past six months.
Before the age of 12.
During primary school.
Throughout childhood.
At the present time.
Across the person’s lifetime.
The practitioner must use the timeframe stated on the form.
A respondent may answer based on a different period. The practitioner should gently redirect them.
For example:
“That example is helpful. This particular question asks about the past six months. Thinking about that period which answer fits best?”
The practitioner should not change the timeframe to make the question easier.
Reading the question accurately
Where the form uses fixed wording the practitioner should read the question as written.
They should:
Speak clearly.
Use an appropriate pace.
Read the whole question.
Avoid emphasising one answer.
Present all response options.
Allow the respondent time to answer.
Repeat the question if requested.
The practitioner should not shorten or paraphrase a fixed question unless the form’s instructions permit this.
If the respondent does not understand the item the practitioner may repeat it or use an approved explanation.
Presenting response options neutrally
A questionnaire may use options such as:
Never.
Rarely.
Sometimes.
Often.
Very often.
Other forms may use:
Not at all.
Several days.
More than half the days.
Nearly every day.
The practitioner should present each option in the stated order and with a neutral tone.
They should not emphasise one option or suggest which answer fits.
For example they should not say:
“Would you say ‘often’ because you told me it happens at school?”
A neutral response would be:
“The options are never, rarely, sometimes, often or very often. Which one feels most accurate to you?”
Clarifying the meaning of a response option
Respondents may ask what terms such as “often” mean.
If the form provides a definition the practitioner should use it.
If no definition is provided the practitioner should not invent a precise threshold. They can say:
“Please choose the option that best reflects how frequently it happens from your point of view.”
If the answer remains uncertain this can be recorded for clinical review.
Clarifying a question
The practitioner may help the respondent understand a question without choosing the answer.
A safe sequence is:
Read the question as written.
Repeat it if needed.
Identify which word or part is unclear.
Explain that part in neutral language.
Return to the original question.
Ask the respondent to select their own answer.
For example:
Question:
“Do you often avoid tasks that require sustained mental effort?”
Neutral clarification:
“Sustained mental effort means concentrating and thinking for a longer period. Thinking about the timeframe on the form which answer fits best?”
The practitioner should not say:
“This means paperwork or homework. You said you dislike paperwork so the answer would be often.”
When examples are appropriate
Examples can help clarify a broad answer. They should be requested when:
The form asks for an example.
The clinical team requires descriptive information.
The respondent uses a vague term.
The answer is unclear.
The practitioner needs to check what the respondent means.
Useful prompts include:
“Could you give me an example?”
“What happened the most recent time?”
“What would somebody else notice?”
“In which situations does this usually happen?”
“How does this affect everyday life?”
The example should be recorded separately from the selected response where possible.
The practitioner should not use their own example to persuade the respondent to change an answer.
Recording the respondent’s answer
The practitioner should record the answer selected by the respondent.
If the respondent chooses “sometimes” the practitioner should not change this to “often” because the examples sound frequent.
If the practitioner believes an answer is inconsistent they can check it neutrally:
“You selected ‘sometimes’. Later you mentioned that this happens on most school days. Would you like to keep ‘sometimes’ or change your answer?”
The final choice remains with the respondent.
The practitioner may record the apparent difference for the clinician if the form allows comments.
Changing an answer
A respondent may reconsider an answer.
The practitioner should allow them to change it and record the final response clearly.
If paper documentation is being used the correction should follow the WMI Psychiatry record-keeping procedure. The original entry should not be erased or concealed.
For electronic forms the practitioner should make sure that the intended final answer has been saved.
The practitioner should not change an answer after the appointment unless:
The respondent has provided a correction.
A clear data-entry error has been identified.
The approved correction process is followed.
Clinical disagreement with an answer is not a reason to alter it.
Recording uncertainty
A respondent may say:
“I do not know.”
“I cannot remember.”
“It depends.”
“I am between two options.”
“I was not there at the time.”
“I do not understand the question.”
“I do not want to answer.”
These are meaningful responses.
The practitioner should not choose an answer simply to complete the form.
They should follow the questionnaire instructions for missing or uncertain answers. If the form does not explain what to do they should record the uncertainty and seek guidance.
Unanswered questions
A blank response should not automatically be treated as “no” or “never”.
Before submitting the form the practitioner should check whether any required item has been missed.
They can ask:
“I noticed that this question does not have an answer. Would you like to answer it or would you prefer me to record that you were unsure?”
The respondent may choose not to answer. This should be recorded accurately.
Apparent contradictions
Answers may appear inconsistent.
For example a parent selects “never” for losing belongings but later reports that the child loses their school equipment several times each week.
The practitioner should not accuse the respondent of contradicting themselves.
They can say:
“I want to make sure I have recorded this correctly. Earlier you selected ‘never’ for losing belongings. You have now described school equipment being lost several times a week. Would you like to review the earlier answer?”
The respondent may:
Change the answer.
Explain that the situations are different.
Keep the original answer.
Remain unsure.
The practitioner should record the final response and any relevant explanation.
Differences between respondents
A parent and patient may choose different answers.
The practitioner should not produce an average response or select the answer that seems most likely.
Depending on the form they should:
Complete separate forms.
Record each person’s response separately.
Identify who gave each answer.
Record that they disagreed.
Seek guidance if the form only permits one response.
Different accounts may be clinically useful.
Maintaining the order of questions
Where possible the practitioner should follow the form in order.
This reduces the risk of:
Missing items.
Asking the same question twice.
Recording an answer in the wrong place.
Applying the wrong timeframe.
Losing track after a break.
Some forms use instructions such as:
“If yes continue to Question 8.”
“If no move to Section C.”
“Complete this section only for patients under 18.”
These are sometimes called routing or skip instructions.
The practitioner should follow them exactly.
Repetitive questions
Questionnaires may contain items that appear similar. Each question may examine a slightly different experience.
The practitioner should not remove a question because it seems repetitive.
If the respondent asks why questions are repeated the practitioner can say:
“Some questions are similar but look at slightly different aspects. I need to ask each item as it appears on the form.”
Breaks during the form
Long forms may be tiring.
The practitioner can offer a break if the respondent becomes:
Tired.
Distracted.
Overwhelmed.
Irritable.
Distressed.
Unable to process the questions.
Before the break the practitioner should note where they have stopped.
When returning they should:
Confirm the correct patient record.
Confirm the section and question number.
Restate the relevant timeframe.
Check that the respondent is ready to continue.
If the form cannot be completed the practitioner should save the completed section securely and record why the appointment ended.
When to stop the questionnaire
The practitioner should pause or stop if:
The respondent becomes significantly distressed.
Risk or safeguarding information is disclosed.
The person withdraws consent.
The practitioner realises that the wrong form is being used.
The respondent is not able to understand the process.
Confidentiality cannot be maintained.
The appointment becomes unsafe.
The technology fails and secure documentation is not possible.
The form requires clinical judgement outside the practitioner’s competence.
The practitioner is unsure how to proceed.
Completing every question is less important than maintaining safety and accuracy.
Risk questions
Some forms include questions about:
Self-harm.
Suicidal thoughts.
Harm to other people.
Abuse or neglect.
Psychotic symptoms.
Severe deterioration in mental health.
Substance misuse.
Immediate medical concerns.
The practitioner should ask these questions calmly and directly as written.
They should not avoid a risk question because it feels uncomfortable.
A concerning answer must be escalated according to the WMI Psychiatry risk or safeguarding procedure. The practitioner should not wait until the full questionnaire has been completed.
The practitioner should not interpret a questionnaire score as a risk assessment.
Scoring a questionnaire
Some questionnaires can be scored automatically. Others require manual calculation.
An assistant practitioner may only calculate a score if:
This is part of the approved procedure.
They have been trained to do so.
The scoring method does not require clinical judgement.
Their competence has been checked.
The result will be reviewed by a qualified clinician.
The practitioner should not:
Interpret what the score means clinically.
Tell the patient that a threshold confirms a diagnosis.
Alter answers to produce a more consistent score.
Compare the patient informally with other patients.
Use an unofficial online scoring tool.
Complete missing answers to obtain a total.
A score is information for the clinical team. It is not a diagnosis.
Responding to questions about results
A patient or family may ask:
“What did I score?”
“Is that a high score?”
“Does that mean I have ADHD?”
“Did I pass?”
“Does the score rule out autism?”
“What happens next?”
A suitable response is:
“The clinician will review the questionnaire alongside the other assessment information. A questionnaire cannot provide a diagnosis by itself.”
If the procedure allows the raw score to be shared the practitioner may provide it without interpretation. If unsure they should ask the supervising clinician.
Protecting the integrity of the form
The practitioner should not:
Copy items from a restricted questionnaire into an unauthorised document.
Share blank forms outside the approved process.
Photograph or screenshot forms.
Use personal cloud storage.
Email forms through a personal account.
Reproduce copyrighted materials without authorisation.
Leave completed forms visible or unattended.
Discuss individual answers with people who are not involved in the patient’s care.
Only approved copies and systems should be used.
Completing a quality check
Before submitting the form the practitioner should check:
Is this the correct patient?
Is this the correct form?
Is the respondent identified?
Is their relationship to the patient recorded?
Is the date of completion recorded?
Is it clear who attended?
Has the correct timeframe been used?
Have all required questions been addressed?
Are unanswered questions clearly identified?
Are selected responses recorded in the correct place?
Are examples attributed to the correct person?
Are corrections clear?
Have any positive risk responses been escalated?
Has the form been saved in the approved location?
Does the record state whether assistance was provided?
Is any required clinical review clearly requested?
The quality check should identify data-entry errors. It should not be used to change the respondent’s account.
Recording that assistance was provided
The clinical team should be able to see how the form was completed.
A suitable note might state:
“The form was completed during a video appointment with the patient and her mother. Questions and response options were read aloud by the assistant practitioner. Neutral clarification was provided where requested. The answers recorded reflect the responses selected by the patient and her mother.”
If the practitioner provided more substantial support this should be documented.
For example:
“The respondent required several questions to be explained in simpler language and needed additional processing time.”
This information may help the clinician interpret the form appropriately.
4. Clinical Perspective
Clinical pearl: Fidelity matters
The more structured the questionnaire is the more important it is to follow the official wording and instructions.
The practitioner should not assume that changing a few words will have no effect.
Clinical pearl: The respondent owns the answer
The practitioner may notice that an answer does not match the examples provided. Their role is to clarify the difference and allow the respondent to choose the final answer.
Clinical pearl: A blank answer is not a negative answer
Missing information should remain clearly identified as missing, uncertain or declined. It should never be converted into “no” merely to complete a score.
Clinical pearl: The score is only one piece of information
A high screening score does not prove that a person has a condition. A low score does not automatically exclude one.
Interpretation belongs to the clinical team.
Common pitfall: Explaining too much
A lengthy explanation may change the meaning of a standardised question.
The practitioner should use the minimum clarification needed and return to the original wording.
Common pitfall: Giving examples that suggest an answer
Examples should not become a checklist that encourages the respondent to agree.
Where possible ask the respondent for their own example.
Common pitfall: Filling in the gaps
The practitioner may believe that they know what the respondent meant. They should never complete missing answers based on assumption.
Common pitfall: Focusing on the total score
The form may contain important descriptive or risk information even when the total score is low. The practitioner must review the form for items requiring escalation.
When to seek support
The practitioner should seek support if:
They are unsure whether the form is appropriate.
The instructions are unclear.
The respondent does not fit the intended group.
The form requires clinical judgement.
The respondent cannot choose between options.
Important information cannot be recorded within the form.
Two respondents give different answers.
The practitioner notices a concerning disclosure.
The person becomes distressed.
The form appears incomplete or damaged.
The scoring process is unclear.
The patient requests an interpretation of the result.
5. Case Examples
Case Example 1: Choosing an answer for the parent
A parent says:
“It happens quite a lot. I am not sure whether to choose ‘sometimes’ or ‘often’.”
The practitioner should not choose for them.
They might respond:
“Please choose the option that feels closest to your experience. If you remain unsure I can record that you were deciding between the two.”
Case Example 2: An inconsistent answer
A patient selects “never” for forgetting appointments. They later explain that they miss an appointment approximately once a month.
The practitioner might say:
“I want to check that I have recorded this accurately. You selected ‘never’ but you have also described missing an appointment around once a month. Would you like to review your answer?”
The patient decides whether to change it.
Case Example 3: A positive risk response
A questionnaire asks about suicidal thoughts. The patient selects an answer indicating that these thoughts have occurred during the past week.
The practitioner should pause the routine questionnaire and follow the risk escalation procedure. They should not wait to see whether the total questionnaire score is high.
Case Example 4: Two parents disagree
One parent selects “often” and the other selects “rarely” for the same behaviour.
The practitioner should not select “sometimes” as a compromise.
They should record separate accounts or seek guidance about how the form should be completed.
Case Example 5: The wrong timeframe
A questionnaire asks about the past six months. A parent answers using examples from five years ago.
The practitioner should acknowledge the historical example and return to the required period:
“Thank you. This question asks specifically about the past six months. Thinking about that period which answer fits best?”
Case Example 6: Request for interpretation
After completing a form a patient asks:
“My score is above the cut-off. Does this mean I definitely have ADHD?”
The practitioner should explain:
“The score is one part of the information collected. The clinician will review it alongside the rest of the assessment before reaching any conclusion.”
6. Summary
When supporting completion of a structured form the assistant practitioner should:
Use the correct approved version.
Confirm the intended respondent.
Explain the process.
Apply the correct timeframe.
Follow the wording and order.
Present every response option neutrally.
Clarify without leading.
Record the answer chosen by the respondent.
Preserve uncertainty and disagreement.
Follow routing instructions.
Offer breaks where needed.
Escalate risk or safeguarding concerns promptly.
Complete an accuracy and completeness check.
Save the form in the approved location.
Submit it for clinical review.
The practitioner should not:
Select answers for the respondent.
Change an answer based on their own judgement.
Fill in missing information.
omit repetitive questions.
Alter standardised wording without authorisation.
Interpret a score.
Confirm or exclude a diagnosis.
Use unofficial forms or scoring tools.
Continue when the process becomes unsafe.
7. Further Reading
Guidance supplied with each approved WMI Psychiatry form
WMI Psychiatry Assistant Practitioner Role Description
WMI Psychiatry Clinical Record-Keeping Policy
WMI Psychiatry Information Governance Policy
WMI Psychiatry Risk Assessment and Escalation Procedure
WMI Psychiatry Safeguarding Policy
WMI Psychiatry Consent and Confidentiality Policy
The official administration and scoring instructions for each authorised questionnaire
8. Reflective Exercise
The learner should consider:
Why might changing the wording of a question influence the answer?
How would you respond if a parent repeatedly asked you to choose an answer for them?
What would you do if a questionnaire did not explain how to record “I do not know”?
How would you manage two respondents who disagree?
Why must a screening score not be treated as a diagnosis?
What should you check before using a questionnaire for the first time?
How would you explain the difference between helping to complete a form and interpreting it?
What steps would you take if risk information appeared halfway through the form?
The learner should discuss their responses with their supervisor.
9. Practical Competency Activity
The learner should complete an approved WMI Psychiatry form using a fictional respondent.
The exercise should include:
A fixed timeframe.
Set response options.
An unclear question.
A request for an example.
One missed question.
One uncertain response.
An apparent contradiction.
A difference between two informants.
A positive risk response.
A request for interpretation of the final score.
The learner should demonstrate that they can:
Confirm the correct form and respondent.
Explain the purpose of the questionnaire.
Follow the wording and order.
Use the correct timeframe.
Present response options neutrally.
Clarify without suggesting an answer.
Record uncertainty accurately.
Address an apparent inconsistency appropriately.
Escalate a risk response promptly.
Complete a final quality check.
Store the completed form securely.
Explain that interpretation belongs to the clinical team.
The supervisor should compare the completed form with the fictional respondent’s answers. Any transcription errors, omitted items or inappropriate interpretations should be reviewed before competency is signed off.
10. Knowledge Check
Complete the short knowledge check below to consolidate your learning and check your understanding of the key principles covered in this lesson. You can review the lesson content again before submitting your answers.
