BANA Outpatient Feedback

BANA Outpatient Feedback Form

The purpose of this feedback section is to ensure that the BANA Outpatient Program is delivering meaningful programming. Please feel free to share your thoughts on our clinical services.

1. Please you share what stage of treatment you are currently in?

In Treatment

Completed Treatment (Select 1)

CBT-E

CBT-T

CBT-AR

In Body Image Group

Completed Body Image Group

Completing Post Treatment Follow Up or Check in Appointments

Withdrew from Treatment

If you withdrew from treatment, could you share what led to this choice.

2. IF YOU HAVE BODY IMAGE GROUP... to what extent do you think the information you learned treatment will be helpful in your everyday life?

Extremely Unhelpful

Somewhat Unhelpful

Neutral

Somewhat Helpful

Extremely Helpful

2.1 Please tell us why?

3.1 Please tell us why?

4. How helpful and supportive did you find nutritional counselling ?

Extremely Unhelpful

Somewhat Unhelpful

Neutral

Somewhat Helpful

Extremely Helpful

4.1 Please tell us why?

5.1 Please tell us why?

6. Please tell us about your experience with your treatment providers and/or BANA staff. We would love to know about your positive experiences and places where you feel we could grow. Please select the provider(s) you would like to tell us about.

Social Worker

Dietitian

Nurse Practioner

Psychaitrist

Other

6.1 Please indicate staff name(s) with comments:

7. How did you feel in our physical space? Is there anything you would suggest we consider changing?

8. Any Additional Comments? ie, hours of operation, length of treatment, parking, etc.

9. Your feedback is incredibly valuable. We sometimes use anonymous or attributed quotes from clients/service recipients in reports or media campaigns. Do you consent to have your written feedback and/or comments from this form being used ?

Yes

10. If you answered "Yes" to the question above, please indicate how you would allow your feedback to be used in a testimonial:

I consent to my feedback being used and attributed with my name (e.g., "Jane D. Smith, Attendee")

I consent to my feedback being used anonymously (e.g., "A presentation attendee")

10.1 If you would like to be attributed, please provide your Name (Optional):