Your Role

Professional Professional and Parent Parent Other Relation
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About You

Are you an individual with Autism?

Yes No
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 Mr Mrs Miss Mx Dr Prof
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 Male Female Not Specified
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 Antrim Armagh Carlow Cavan Clare Cork Donegal Down Dublin Fermanagh Galway Kerry Kildare Kilkenny Laois Leitrim Limerick Londonderry/Derry Longford Louth Mayo Meath Monaghan Offaly OTHER Roscommon Sligo Tipperary Tyrone Waterford Westmeath Wexford Wicklow Other
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Preferred method of Contact (Please select all that you would prefer)

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About your profession

Behaviour Therapist Classroom Assistant Education Professional Education Psychologist HSE (Primary Care + Disability Staff Only) Occupational Therapist Physiotherapist Speech and Language Therapist Teacher Teaching Assistant Other
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Nursery/Play/Pre School Mainstream Primary Special Education Setting/Autism Unit Post Primary Further/Higher/Technical Educational Setting University Home Schooled None Other
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How long have you been working with children/young people with autism?

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
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About the Child/Children you are related to that have autism

Male Female Not Specified
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Date of birth
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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January February March April May June July August September October November December
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1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
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1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
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 Nursery/Play/Pre School Mainstream Primary Special Education Setting/Autism Unit Post Primary Further/Higher/Technical Educational Setting University Home Schooled None Other
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Autism ASD Asperger syndrome ASC PDA Awaiting Diagnosis Other

Which are the main areas currently affected by autism?

Anxiety Attention Behaviour Communication Daily Living Skills Family Life Interests and Hobbies Learning People and Places Physical Activity/Motor Skills School Attendance Sensory Processing Sleep Socialising and Play Transitions Between Activities

Diagnosed co-occurring conditions?

Anxiety Disorder Attention-deficit Hyperactivity Disorder (ADHD) Cerebral Palsy Developmental Coordination Disorder (DCD) Down Syndrome Dyslexia Dyspraxia Obsessive-compulsive Disorder (OCD) Oppositional Defiance Disorder (ODD)
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About the Child/Children you work with

0-3 4-10 11-16 17-19 19+
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 Nursery/Play/Pre School Mainstream Primary Special Education Setting/Autism Unit Post Primary Further/Higher/Technical Educational Setting University Home Schooled None Other
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Join our research panel

As a member of the Centre’s Research Panel, you will be part of a community of professionals, parents, relatives and people with autism, who provide the Centre with valuable views and opinions on services and issues affecting those working or living with a child or young person with Autism.

Please note that as a member of the Research Panel you could be asked to participate in a range of autism and education research projects, which may take the form of taking part in focus groups, face to face interviews, telephone, email or postal surveys or by any other reasonable means of communicating with you. You will take part in no more than four research projects in any given year.

Participation is voluntary and the Centre is committed to protecting your privacy.

Your knowledge and expertise will be an invaluable contribution to Middletown Centre for Autism, in aiding strategic decisions to help improve the education of children and young people with Autism in both Northern Ireland and the Republic of Ireland.

Middletown Centre for Autism will use the information you provide for research, administration, analysis and marketing. The Centre or a research organisation working on behalf of the Centre, may contact you again for research purposes only, by letter, telephone or other reasonable means of communication. At all times, your personal details will be kept secure and confidential.

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