Family Carers' Email Network: Application Form About yourself Question Title * 1. Your contact information Name Address Address 2 City/Town County Post Code Country Email Address Phone Number Question Title * 2. Gender Female Male Other Don't wish to disclose Question Title * 3. Year of Birth Question Title * 4. Your main language (for example, English/ Polish /Punjabi)Please leave blank if you do not wish to disclose We collect this information as it helps to ensure we are inclusive and we use it in our funding bids which allow the Family Carer Email Network to continue Question Title * 5. Your Ethnicity (Please pick from the drop down next to which box best describes your background) A) White English/ Welsh /Scottish/ Northern Irish/British Irish Gypsy or Irish Traveller White - Other White and Black Caribbean White and Black African White and Asian Mixed/Multiple ethnic background - Other Indian Pakistani Bangladeshi Chinese Asian – Other African Caribbean Black/African/Caribbean – Other Arab Any other ethnic group I do not wish to disclose this A) White menu B) Mixed/Multiple Ethnic Groups English/ Welsh /Scottish/ Northern Irish/British Irish Gypsy or Irish Traveller White - Other White and Black Caribbean White and Black African White and Asian Mixed/Multiple ethnic background - Other Indian Pakistani Bangladeshi Chinese Asian – Other African Caribbean Black/African/Caribbean – Other Arab Any other ethnic group I do not wish to disclose this B) Mixed/Multiple Ethnic Groups menu C) Asian/Asian British English/ Welsh /Scottish/ Northern Irish/British Irish Gypsy or Irish Traveller White - Other White and Black Caribbean White and Black African White and Asian Mixed/Multiple ethnic background - Other Indian Pakistani Bangladeshi Chinese Asian – Other African Caribbean Black/African/Caribbean – Other Arab Any other ethnic group I do not wish to disclose this C) Asian/Asian British menu D) Black/African/Caribbean/Black British English/ Welsh /Scottish/ Northern Irish/British Irish Gypsy or Irish Traveller White - Other White and Black Caribbean White and Black African White and Asian Mixed/Multiple ethnic background - Other Indian Pakistani Bangladeshi Chinese Asian – Other African Caribbean Black/African/Caribbean – Other Arab Any other ethnic group I do not wish to disclose this D) Black/African/Caribbean/Black British menu E) Other ethnic group English/ Welsh /Scottish/ Northern Irish/British Irish Gypsy or Irish Traveller White - Other White and Black Caribbean White and Black African White and Asian Mixed/Multiple ethnic background - Other Indian Pakistani Bangladeshi Chinese Asian – Other African Caribbean Black/African/Caribbean – Other Arab Any other ethnic group I do not wish to disclose this E) Other ethnic group menu F) Prefer not to say English/ Welsh /Scottish/ Northern Irish/British Irish Gypsy or Irish Traveller White - Other White and Black Caribbean White and Black African White and Asian Mixed/Multiple ethnic background - Other Indian Pakistani Bangladeshi Chinese Asian – Other African Caribbean Black/African/Caribbean – Other Arab Any other ethnic group I do not wish to disclose this F) Prefer not to say menu Question Title * 6. How did you hear about the email network? About your family member with challenging behaviour Question Title * 7. Name Question Title * 8. Date of birth In the format DD/MM/YYYY Date Question Title * 9. Age Question Title * 10. Gender Female Male Other Don't wish to disclose Question Title * 11. What level of Learning Disability does your family member have?(NB this network is only for people whose relative has a severe learning disability) Severe/Profound Learning Disability Moderate Learning Disability Mild Learning Disability Not sure Question Title * 12. Does your family member have a diagnosed syndrome/condition? (please specify)E.g. ASD, Down Syndrome, Smith Magenis etc. Question Title * 13. What level of communication does your family member have? No speech Some words and phrases Full sentences Question Title * 14. Where does your family member live? Family Home Assessment & Treatment Unit Care Home Residential school/college Supported Living Their own home Other Question Title * 15. Type of challenging behaviour – Please pick any behaviour/s your family member displays Self-Injury (e.g. head banging, self-biting, skin picking) Physical Aggression (e.g. kicking, biting, pulling hair) Verbal Aggression (e.g. screaming, vocalisations, excessive swearing) Destruction of property or the environment (e.g. ripping clothes, breaking furniture) Stereotyped Behaviours (e.g. rocking, spinning, hand flapping) Inappropriate or unacceptable sexual behaviour (e.g. masturbating in public, touching others inappropriately) Smearing and urination (e.g. smearing faeces, urinating in inappropriate places) Stealing (e.g. taking possessions/food which do not belong to the individual) Non-compliant behaviour (e.g. refusing to move, refusing to engage in an activity) Absconding (e.g. running away when out in the community or from home, school or other setting and has no awareness/understanding of the potential risks) Pica or polydipsia behaviour (eating inedible objects, such as clothes, stones and cigarette butts OR drinking excessively which can include non-consumable liquids e.g. shampoo, cooking oil or cleaning fluids) Submit