Express your interest in our focus group Please complete this expression of interest form to take part in one of our two focus groups taking place on Wednesday 23 April. We only have 10 spaces, and we would like to consult with parents with a range of experiences and backgrounds. We’re looking for some parents and carers who know something about Contact to join one of our two small focus groups taking place in April and tell us what you think about what we do and how we come across. Whether you are relatively new to Contact or have been using our services for years, we’d like to hear from you. We are currently taking a good look at Contact’s brand and want to make it better so more families know about us and how we can help them overcome the daily challenges they face. As someone who has already found Contact, your help to get this right will be invaluable. With your help, we’ll be able to make sure that we’re using the right messages and make it easier for other parent carers to find us and know that they can turn to us if they need support. About you Are you the parent/carer/guardian of a child with additional needs, disability or health condition between 0-25 living in the UK? Yes No First Name Last Name Postcode Telephone Number Email Address Age What is your gender? Female Male Other Prefer not to say Prefer to self describe Your ethnicity: Please select Asian / Asian UK: Bangladeshi Asian / Asian UK: Chinese Asian / Asian UK: Indian Asian / Asian UK: Pakistani Asian / Asian UK: Any other Asian background Black / African / Caribbean / Black UK: African Black / African / Caribbean / Black UK: Caribbean Black / African / Caribbean / Black UK: Other background Mixed / multiple ethnicity: White & Asian Mixed / multiple ethnicity: White & Black African Mixed / multiple ethnicity: White & Black Caribbean Mixed / multiple ethnicity: Any other origin White: English / Scottish / Welsh / Northern Irish / UK White: Irish White: Gypsy or Irish Traveller White: Any other White background Other ethnic group: Arab Any Other Origin Prefer not to answer Where in the UK do you live? Please select England Northern Ireland Scotland Wales About your child or children Can you tell us about your child or children’s disability or medical condition? Please tell us which of the following your children/child has (tick all that apply). ADHD Autistic Spectrum Disorder Complex health need Hearing impairment Learning disability Life limiting or life threatening condition Multisensory impairment Physical disability Social, emotional or mental health difficulties Speech, language or communication difficulties Rare condition Visual impairment Undiagnosed Prefer not to say Other How many years have you known Contact? Less than 3 years More than 3 years Have you used any of Contact's services, e.g. our website or social media, parent workshops or helpline, for the first time in the last three years? Yes No How many of Contact's services have you used in the last three years? 1 service 2-3 services More than 3 services Have you ever donated to Contact to taken part in one of Contact's fundraising events? Yes No Submit