Name *

First Name

Last Name

What is the name and address of the facility?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Did you receive treatment as an: *

Inpatient?

Outpatient?

Day-patient/step-up patient?

Was the service: *

An eating disorder facility?

A general ward or diabetes-focused service (based primarily on physical stability)?

A psychiatric unit or ward (covering a range of different psychiatric conditions including eating disorders)?

Overall do you think that your experience was: *

Positive

Negative

Neutral

Was the treatment funded by: *

The NHS

Private by myself or loved ones

A private bed paid for by specialist NHS funding (If so please do explain how easy or difficult it was to obtain this funding further down the page)