Carers of Autistic Adults Peer Support Group Protected Characteristics

Carers of Autistic Adults Peer Support Group
Name*

First NameLast Name
E-mail*
example@example.com
I am a Carer

Yes
Phone number:*
I am happy to be included in a Whats App group.*

Yes, please use the mobile number above.No thank you
Where did you hear about the group?
What age bracket do you fall into:*

18-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475+
What is your religion? :*

No religionChristian (including Church of England, Catholic, Protestant and all other Christian denominations)MuslimHinduSikhJewishBuddhistPrefer not to sayOther
What ethnic group do you fall in?*

WhiteMixed or multiple ethnic groupsAsian or Asian BritishBlack, Black British, Caribbean or AfricanArabOther
What ethnic sub-group do you identify with?

White: English, Scottish, Welsh, Northern Irish or BritishWhite IrishWhite Gypsy or Irish TravellerWhite: RomaWhite: Other
What ethnic sub-group do you identify with?

Mixed or multiple Ethnic Groups : White and Black CaribbeanMixed or multiple Ethnic Groups: White and Black AfricanMixed or multiple Ethnic Groups: White and AsianMixed or multiple Ethnic Groups: Other
What ethnic sub-group do you identify with?

Asian or Asian British: IndianAsian or Asian British: BangladeshiAsian or Asian British: PakistaniAsian or Asian British: ChineseAsian or Asian British: Other
What ethnic sub-group do you identify with?

Black, Black British, Caribbean or African: CaribbeanBlack, Black British, Caribbean or African: AfricanBlack, Black British, Caribbean or African: Other
Do you have any disability, physical or mental health conditions or illness lasting or expected to last 12 months or more? *

YesNoPrefer not to say
Do any of your disabilities, conditions or illnesses reduce your ability to carry out day to day activities? For example, eating, washing, walking or going shopping.*

Yes a lotYes a littleNot at allPrefer not to sayOther
What is your sex*

MaleFemaleNon-binaryPrefer not to sayPrefer to self-describe
Is your gender identity the same as your sex registered at birth?*

YesNoPrefer not to say
Which of the following best describes your sexual orientation?*

Heterosexual/straightBisexualGay or lesbianPrefer not to sayPrefer to self describe
What is your legal marital or registered civil partnership status?*

Never married and never registered in a civil partnershipMarriedDivorcedFormerly in a civil partnership which is now legally dissolvedIn a registered civil partnershipWidowedSeparated but still legally marriedSurviving partner from a registered civil partnershipSeparated, but still legally in a civil partnershipPrefer not to say
What neighbourhood do you live in?*

Beckton and Royal DocksCustom House and Canning TownEast HamForest GateManor ParkPlaistowStratford and West HamPrefer not to sayOther
Which of these activities best describes what you are doing at present?

Employed in a full time jobEmployed in a part time jobSelf-employed (full or part-time)Permanently retiredStudying part-time or full-time (i.e. at school, college or university)Looking after home or familyPermanently sick or disabledOn a government supported training programme (e.g. Modern Apprenticeship/Training for Work)On maternity/paternity leave/shared parental leaveUnemployedPrefer not to sayOther
Emergency Contact *
Name and phone number
I am a member of the following Newham groups:
Should be Empty: