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Special Interest and Regional Group Survey 2012
Special Interest and Regional Group Survey Form
Your Name:
Contact Email Address:
Please use an email address you may be happy for others to use to contact you.
Are you in a regional group?
Please select...
Yes
No
Please select...
Scotland
Republic of Ireland
Northern Ireland
North West
North East
Yorkshire and the Humber
Wales
West Midlands
East Midlands
East of England
South West
South East
London
Other
Please state where you are based? (including country if not in the UK or Ireland)
Are you happy for SI Network to share your email with the Regional and Special Interest Group Co-ordinators and your Regional Lead ?
Yes
No
Are you the Lead of a Regional Group?
Yes
No
Are you happy for your email address to receive emails from other members in your area. These will be rerouted to your email address, your email address will not be shared with others.
Yes
No
Please use an email you are happy for us to forward emails to. These emails will be from people who may want to join the regional group.
Please state the focus or clinical areas your groups covers: (please mark all that apply)
Mental Health
Learning Disability
DCD/Dyspraxia
CAMHS
ASD/ASC
Inpatient
Community
Paediatrics
Adolescents (Secondary School Aged)
Adults
Older Adults
Special School
Parent Group
Service User/Lived Experience Group
Infants and Toddlers
School Based OT
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