**Please note this version is now closed. Please follow this link to complete the survey as a Google Form https://forms.gle/2ednEqRwULYPYDaj7 ** 

Have you been affected by perinatal mental illness? Would you like to use your voice to help improve services for women and families in Scotland at a local or national level? Why not join the Experts by Experience Reference Group – you can be involved at a level to suit you. Please complete the form to be kept up to date with opportunities.

We hope that this will allow the voices of women and families to be represented in perinatal mental health service development and policy development.

Please complete the following form to allow us to get in contact with you, and to ensure the diversity of the work. We would welcome involvement from women and families from all communities, including, but not restricted to: mothers, fathers, ethnic minority communities, refugees and those seeking asylum, those in the justice system, Gypsy and Traveller communities, LGBT parents, people who live in rural areas and those living with disabilities and mental illness. 

Sharing your details here does not imply that you have any obligation to take part in any of the work of this group. You are welcome to be involved at any level you feel comfortable with, and you are welcome to withdraw your interest and details at any point. Involvement will not have any effect on your care and treatment. Please contact clare.thompson@maternalmentalhealthscotland.org.uk if you require further information.

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* 1. What is your name?

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* 2. What is your email address?

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* 3. How old are you?

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* 4. I am: 

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* 5. I am:

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* 6. I am:

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* 7. What health board do you reside in?

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* 8. I am a 

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* 9. As an expert by experience, I am interested in being part of:

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