Lived Experience Network Submission Form
First Name:
Contact Number:
Birth Year
Postcode
Last Name:
Email Address:
State
Please select...
Western Australia
New South Wales
Australian Capital Territory
Victoria
Tasmania
South Australia
Queensland
Northern Territory
City/Town
What is your geographical classification?
Regional
Remote
Metropolitan
What is your Gender?
Man
Woman
Non-binary
Prefer to self-describe
Prefer not to say
Other
Please describe gender:
Do you identify as:
Aboriginal or Torres Strait Islander
LGBQTIA+
None of the above
What is your employment status?
Employed, Full time
Employed, Part time
Full time carer
Never employed
Unemployed, Looking for work
Unemployed, Not looking for work
Unable to work
Retired
Prefer not to say
Relationship to autism (select all that apply):
Autistic adult, self-diagnosed
Autistic adult, diagnosed
Parent/carer of an autistic child
Parent/carer of an autistic adult
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
Learning disabilities (eg 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
Policy 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+ Rights
NDIS
Autism Assessment & Diagnosis
Tools, Supports and Resources for Autistic People
Caring and Carers
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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