Finding Care Self-Assessment Feedback Form

Level of Care Self-Assessment (LoCSA) Feedback Form
Thank you for completing the self-assessment!

We hope this tool will help you and your family doctor decide what level of care may be suited for your needs at this time.

Now that you have reviewed your recommendations, we kindly ask that you complete the following feedback form.

Consent
Before providing your feedback, we would like to know how we can use your feedback.

There are two ways your feedback can help us:

1. Research: If you choose to provide this information and participate in our ground-breaking research, your data will be de-identified (stripped of your personal information) and aggregated (put into a data set with thousands of other people's data) before being analyzed by our researchers.

2. Advertising: If you choose to provide this information and allow us to use your comments in promotional materials, all comments will be anonymous and, if used, would be cited as “participant comment.”

Please note, your participation is completely voluntary and choosing not to participate will not impact your ability to access support sessions.
Can we use your survey responses (anonymously, of course) in future research efforts?*

YesNo
Can we contact you by email to inform you of future research projects related to this tool?

YesNo
Name

First NameLast Name
Email
example@example.com
Do you give Body Brave permission to use your comments in our publication materials, either online or in print? All comments are anonymous and, if used, would be cited as “participant comment.”*

YesNo

How You Found the Self-Assessment
How did you learn about the self-assessment?

St. Joseph’s Eating Disorder Clinic websiteThe Recovery Support Program on CareteamMy healthcare provider (e.g., family doctor, dietitian, etc.)Other
Please indicate how you learned about the self-assessment

	Strongly disagree	Disagree	Neither agree or disagree	Agree	Strongly agree
The self-assessment is user-friendly
I found the "Why is This Question Asked" explanations helped me understand why a particular level of care might be recommended for me
The self-assessment helped me gain awareness of how my eating disorder or struggles with food, weight, or body image are impacting me
The self-assessment explained clearly which level of care might be best for me.

Level of Care Self-Assessment (LoCSA) Feedback Form