Expression of Interest | Footprints Community Head to Health Co-design Workshop in Logan

Footprints Community invites members of the community from Logan to participate in consultation and co-design workshops for the design and establishment of the Head to Health Satellite Clinics in 2024 in Logan.

The aim for the Satellite Clinic is to:

Support people who are experiencing mental health distress to have an easily accessible local space to get immediate advice and support to reduce mental and emotional distress.

Connection for people accessing the service to specific mental health related services that suit / match individual needs.

Knowing that Head to Health is the local access point for support and information for mental health.

The information you provide is confidential and Footprints strictly adheres to the Privacy Act 1988 (Cth), Information Privacy Act 2009 (Qld), the Privacy and Personal Information Protection Act 1998 (NSW) and the Health Records Information Privacy Act 2002 (NSW). You can request for your information and data to be withdrawn at any time.

Thank you for your interest in the co-design workshops.

Footprints Community

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* 1. First name

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* 2. Surname

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* 3. Email address

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* 4. Best contact number

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* 5. Gender

Non-binary

Woman

Man

Prefer not to say

Prefer to self-describe as (please specify)

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* 6. If you would like to, please share your pronouns

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* 7. Date of birth

This is to ensure 18+ participants

Date

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* 8. Street address

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* 9. Suburb

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* 10. State

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* 11. Post code

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* 12. Please list any dietary requirements

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* 13. Do you identify as a member of any of these groups?

LGBTQIA+

CALD (Culturally and linguistically diverse, e.g., language spoken other than English, first or second-generation Australian)

Aboriginal or Torres Strait Islander

Living with a disability

Other (please specify)

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* 14. Is there anything additional we can do to support you during the workshops?

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* 15. Alternative contact person

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* 16. Phone number for alternative contact person

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* 17. Alternative contact person's relationship to you

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* 18. Please select all that apply to your lived experience / interest

I have a lived/ living experience of mental health and/or emotional distress

I have cared for someone with a lived/ living experience of mental health and/or emotional distress

I am family/kin to someone with a lived/ living experience of mental health and/or emotional distress

I am a community elder/ leader

I am a concerned/ interested member of the community

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* 19. Are you currently accessing, or have you previously accessed mental health services (public or private)? Please choose 1 option only.

Yes

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* 20. Briefly explain what you hope to achieve by attending the co-design workshop(s)

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* 21. Please read each statement and indicate your agreement before submitting your application

I understand that completing this Expression of Interest Form registers my interest in attending this workshop and does not guarantee participation in the co-design process.

I may be contacted by Footprints Community, or a third-party evaluator, to discuss my expression of interest.

I believe that getting involved will not cause me harm.