Consumer and Carer Participation Registration of Interest

*First Name:  *Required

*Surname:  *Required

*Address:  *Required

*Suburb:  *Required

*Postcode:  *Required

Email: 

Phone: 

Mobile: 

Date of Birth: 

Male Female

*Method of Contact: Please select from the list below your preferred means of contact:*Required
A Selection Required Phone Email Letter

*1. Tell us about yourself?*Required

*2. Why do you want to be involved in the COPMI national initiative?*Required

*3. Please describe your areas of interest?*Required

*4. What type of COPMI activities would you like to be involved in?*Required
Some examples include: COPMI e-List, focus groups, COPMI National Family Forum, workshops, Peer Reviewer for information, resources or research, education and training of workers, workforce development, media and communication, COPMI newsletter, groups for particular communities or interest groups (eg rural consumers and carers, young carers).

*5. Are you involved with any other organisations? If yes, which organisations and what is your involvement?*Required

*6. Please provide a brief description of your experience or skills that you are believe are relevant to this area.*Required

7. Do you identify as being an Aboriginal person or Torres Strait Islander? Yes No

8. What languages do you speak at home? 

8a. Where were you born? 

8b. Where were your parents born? 

9. Are you from a rural or remote area? Yes No

10. Do you identify as being a child (under 18 years) of a parent with a mental illness? Yes No

10a. Is this something that you would be happy (and feel comfortable) talking about? Yes No

11. Do you identify as being a consumer who is a parent? Yes No

12. Do you identify as being the carer of a parent with a mental illness? Yes No

13. Do you identify as being the carer of a child of a parent with a mental illness?
(e.g., grandparent, foster carer). Yes No

14. Is there anything else you would like to tell us?

Please go over the information that you have added to check the accuracy of the information. If you are satisfied check the Information Accurate box, fill in the anti-spam box and then click submit.

* Information AccurateYes *Required

*As an anti-spam measure, please type the word 'submit' in the field below:
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