Lived Experience Network Submission Form

First Name:

Last Name:

Contact Number:

Email Address:

Birth Year

Postcode

State

City/Town

What is your geographical classification?

RegionalRemoteMetropolitan

What is your Gender?

MaleFemaleNon-binaryPrefer to self-describePrefer not to sayOther

Please describe gender:

Do you identify as:

Aboriginal or Torres Strait Islander

LGBTQIA

Culturally and Linguistically Diverse

What is your employment status?

Employed, Full time Employed, Part time Full time carer Never employedUnemployed, Looking for work Unemployed, Not looking for work Unable to work Retired Prefer not to say

Your relationship to autism (Tick all that apply)

Autistic adult, self-diagnosedAutistic adult, diagnosed

Your child(s) relationship to autism (Tick all that apply)

Parent/carer of an autistic childParent/carer of an autistic adultParent/carer of an autistic child with very high support needsParent/carer of an autistic adult with very high support needs

Note: The term ‘very high support needs’ refers to Autistic people who usually require ongoing 24/7 care. There are several different definitions and terms for this cohort of the community, including ‘profound autism’, and ‘autism with complex support needs’.

At what age did you receive your diagnosis?

Before age 5 5 – 10 years old 10 – 18 years old Adulthood

What is the age of the child that you support:

Pre-school age Primary school age Secondary school age

At what age did the person you support receive their diagnosis?

Before age 5 5 – 10 years old 10 – 18 years old Adulthood

What type of school is the child that you support enrolled in?

Mainstream school Special school Online school Homeschool

Do you, or the person you support, have any of the following co-occurring conditions or disabilities (select all that apply)?

ADHD Intellectual disability Epilepsy Mental health conditions (e.g. anxiety, depression)Specific learning disabilities (e.g. dyslexia) Chronic pain Chronic health conditions Other None of the above

Do you, or the person you support, have any of the following co-occurring conditions or disabilities, Other?

I am interested in hearing about opportunities to share lived experience that relates to the following areas (select all that apply):

Media opportunities Autism with very high support needsPolicy and advocacy Employment Early years and primary education Secondary education Post-secondary education, such as university or vocational training Healthcare Mental health General disability supports Disability rights LGBTQIA+ rightsNDIS Autism screening, assessment & diagnosis Supports and resources for Autistic people Carers and caring supports

In 100 words or less, tell us why you are interested in contributing your lived experience to support and inform our work.

I acknowledge that I have read and agree to the Terms of Reference

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