Mental Health Drug and Alcohol Lived Experience Network registration form

Thank you for your interest in being part of the Mental Health, Drug and Alcohol Lived Experience Network.

Please tell us a bit about you and your interest by filling out the form below.

What you include in this form is confidential and will not be linked to your health care record. Read our Privacy Statement for more information.

We will only contact you when we are looking for input to help improve our services, or to give you an update on a project you took part in.

First Name *

Surname *

Contact phone *

Email address *

Suburb / Area where you live *

Year of birth *

What is your experience of mental health, drug or alcohol issues?

Personal experienceExperience as a carer or support personBoth caring and personal experienceNone / prefer not to say

Which type of service(s) does your experience relate to?

Mental Health Acute UnitRecovery ProgramOlder Person’s Mental Health UnitCommunity Mental Health serviceCommunity Drug and/or Alcohol serviceEmergency DepartmentNoneOther

Please specify *

Are you of Aboriginal or Torres Strait Islander origin?

NoYes, AboriginalYes, Torres Strait IslanderYes, Both Aboriginal and Torres Strait IslanderPrefer not to say

Is there anything you would like to tell us about your experience or interests?maximum of 250 words

Thanks for joining the Lived Experience Network. We will be in touch with you soon to confirm your registration. If you have any questions, please contact us on mlhd-mhda-experiences@health.nsw.gov.au

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