Emotionally-Based School Avoidance

Name *

Email *

Please use your registered organisation email address if you have one

Are you a professional (employee, volunteer or foster carer) working with children and young people who are living in Liverpool or who have a Liverpool-based GP * Yes
No

Are you a parent/carer of a child or young person living in Liverpool * Yes
No

Organisation *

Organisation Area * Select ... Alternative education Children centre Further education Higher Education Hospital Housing Leisure Local Authority Nursery Other Parent/Carer Police Primary Care Primary School Residential Secondary School Social care Special School Voluntary Sector Youth work

Post * Select ... Child / Young person Community Paediatrician Community worker Councilor Counsellor GP Health visitor Housing officer Lecturer Leisure centre worker Librarian Manager Mental health practitioner Mentor Nurse OT Other Parent/Carer Physiotherapist Police officer Psychiatrist Psychologist School health practitioner School governor Social worker Speech & Language therapist Student Support worker Teacher Teaching assistant Volunteer Youth worker

Address *

City/Town *

County *

Post Code *

Phone *

Gender Select ... Male Female Transgender Prefer not to say

Sexuality Select ... Gay/Lesbian Bisexual Heterosexual Prefer not to say

Racial Origin Select ... White: British White: Irish Gypsy / Irish Traveller / Romany Other White backgound White and Black Caribbean White and Black African White and Asian Other Mixed / Multiple ethnic background Asian / Asian British: Indian Asian / Asian British: Pakistani Asian / Asian British: Bangladeshi Asian / Asian British: Chinese Other Asian background Black / Black British: African Black / Black British: Caribbean Black / Black British: Somali Other Black / African / Caribbean background Arab Yemeni Other ethnic group Rather not say

Do you consider yourself to be disabled? * Yes
No

If yes, what arrangements do we need to make to ensure access and participation?

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