Lived Experience Panel Representative Application Form

Personal contact details

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* 1. Name, address, email address, phone number: (Please provide the address, email address and phone number that you would like us to use for any communication about your application or panel activities)

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* 2. Why do you wish to participate in the NSRF LE Panel? (you may tick multiple boxes)

I have lived experience of suicide, self-harm or mental illness.

I have been bereaved by suicide.

I am or have been a carer of someone with lived experience of suicide, self-harm or mental illness.

I have lived experience of mental health issues.

I represent a group of people I think are relevant to these topics.

I am a member of a relevant patient or advocacy group.

Other (please specify)

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* 3. Have you ever participated in research or have been a member of a LE group?

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* 4. Are you comfortable sharing the details of your GP or your personal mental healthcare professional in case of an emergency?

Yes.

No.

Unsure, I would like some more information before replying. (In the case that a LE representative expresses any thoughts of suicide or self-harm, the LE Advisory Group, with the permission of the LE representative, will share this with the individual’s personal mental health professional or GP depending on the situation).

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* 5. To which gender do you most identify?

Male.

Female.

Transgender male.

Transgender female.

Non-binary.

Prefer not to say.

Other (please specify)

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* 6. What is your age in completed years?

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* 7. What is your ethnic or cultural background? (Please select all that apply)

White Irish.

Irish Traveller.

Other White.

African.

Any other Black background.

Chinese.

Any other Asian background.

Other including mixed background.

Prefer not to say.

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* 8. Do you have any of the following long-lasting condidtions? (Please select all that apply)

Blindness, deafness or a severe vision or hearing impairment.

A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, reaching, lifting or carrying.

A learning or intellectual disability.

A psychological or emotional condition.

Other including any chronic illness.

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* 9. Do you require any additional support/equipment to be a LE panel representative? (Do you require any further supports that would make it easier for you to undertake this role, for example, a screenreader or materials in large print?)

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* 10. I declare that the information that I have given is, to the best of my knowledge or belief, true and complete.

Date / Time

Date