Expression of Interest - Carer Consultation Groups

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* 1. Your Name

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* 2. Contact number

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* 3. Email address

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* 4. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 5. Are you caring for a person due to:

Mental Health

Older age and requiring support

Chronic Health Issue

Disability

Other (please specify)

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* 6. Are you of Aboriginal or Torres Strait Islander origin?

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both

Prefer not to say

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* 7. Do you mainly speak a language other than English at home?

No, English only

Prefer not to say

Yes (please specify)

Optional Questions

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* 8. What is your gender?

Female

Male

Non Binary

Prefer not to say

Other (please specify)

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* 9. Do you identify as a member of the LGBTIQA+ community?

Yes

Prefer not to say

Carers Victoria thanks you for completing this survey.

If you have any queries regarding this form or the consultation, please don't hesitate to contact the Events Team at events@carersvictoria.org.au