Autistic Doctors Programme Registration Form

Welcome and thank you for your interest in applying for a place on the Autistic Doctors programme. Please fill out this survey to finish your registration application with Thriving Autistic. We will be in touch as soon as possible to let you know if your application has been successful.

Question Title

* 1. Your contact info:

First Name

Last Name

Country

Email Address

Question Title

* 2. Your pronouns

Question Title

* 3. Would you like us to store your information for entry onto a subsequent iteration of this programme if this programme application is unsuccessful?

Please note - if there is a high volume of applications for this programme we may do our best to match cohorts together (eg a programme for trainees or a programme for those who share similar goals)

Yes - please store my information securely and update me when you next run this programme

No- please delete my information if this application is unsuccessful.

Question Title

* 4. In what year were you born? (enter 4-digit birth year; for example, 1986)

Question Title

* 5. Do you confirm you are over 18 years, Autistic (self-identified or diagnosed) and working or training as a medical professional?

Yes

Other (please specify)

Question Title

* 6. Please describe your current career status (eg I am in 2nd yr training placement / I am on leave due to XXX / I am at mid-career working in X setting)

Question Title

* 7. Do you have any access needs? (Select all that apply)

I do not have any access needs

I need a Sign Language Interpreter

I need captions turned on

I need my camera off

I need to use text rather than voice communication

I need a support person to attend sessions with me

I need additional time to process my thoughts

Other (please specify)

Question Title

* 8. How familiar are you with the Neurodiversity Movement and the Neurodiversity Paradigm?

Not at all familiar

Somewhat familiar

Advanced knowledge

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 9. What are your main priorities that you would like to be addressed in this programme?

Question Title

* 10. Choose as many or as few of the topics that interest you below:

Exploring my communication and processing styles

Identifying where/when/why communication is difficult

Emotional expression

Emotional regulation strategies

Self-care and practical strategies for time management etc

Self-advocacy; setting and expressing boundaries and needs at work

Masking

Suggest other topics you would like to learn more about

Question Title

* 11. Express your preferences for experiential activities

	most preferred	neutral	least preferred	I would not do this
Role Play	Role Play most preferred	Role Play neutral	Role Play least preferred	Role Play I would not do this
Creative Writing	Creative Writing most preferred	Creative Writing neutral	Creative Writing least preferred	Creative Writing I would not do this
Visual Art	Visual Art most preferred	Visual Art neutral	Visual Art least preferred	Visual Art I would not do this

Other (please specify)

The following series of questions are a safety check on your wellbeing. This group programme is not suitable for those at risk. If you are in danger of harm please tell someone and see your GP.

Question Title

* 12. I am not currently misusing drugs or alcohol

I am not currently misusing drugs or alcohol

I am currently misusing drugs or alcohol

Other (please specify)

Question Title

* 13. I am not actively suicidal

I am not actively suicidal

I am actively suicidal

Question Title

* 14. I am not at risk of harm to myself or others

I am not at risk of harm to myself or others

I am at risk of harm to myself or others

Question Title

* 15. I understand that if a risk is disclosed during any of the workshops, then the facilitator is obliged to break confidentiality and seek support for me.

Yes I agree

No I don't agree

Question Title

* 16. Who should we contact in case of concern for your safety?

Full name

Relationship to you

Contact phone number

Question Title

* 17. Do you have any other comments, questions, or concerns?

100% of survey complete.