MENTAL HEALTH

CONSUMER / CARER REPRESENTATIVE

GENERIC EXPRESSION OF INTEREST v2
Forensic Mental Health Sub Network
Thank you for registering an interest in becoming a consumer / carer representative with Mental
Health Services across all levels (Districts, Areas, and State).
It is essential that we have consumer and carer feedback across all levels of mental health. We
recognise that everybody has something to contribute and so encourage you to complete this
form.

When you complete this form and return it to the Principal Project Officer Consumer
Engagement and Consultation your information will be put onto a Statewide database which will
be used to identify and recruit consumer and carer representatives for a variety of working
groups, committees or interview panels across the State.

When a position becomes available for a consumer or carer representative we will be able to
look onto the database and provide appropriately experienced consumers and carers to fill the
vacancy.

Please submit your Expression of Interest to Principal Project Officer Consumer and
Carer Participation at PO Box 2368 FORTITUDE VALLEY BC QLD 4006

PERSONAL INFORMATION

Family Name:______________________ Given Name: __________________________

Address: ___________________________________________________________________

Town / Suburb:__________________ State: __________ Postcode: _________________

Telephone Number: _____________________ Mobile Number: __________________

Fax Number: ____________________ Email Address: ______________________________

 EXPERIENCE / SKILLS / INTERESTS

Do you identify as a: ο Consumer ο Carer

Could you please share some of your experiences as a consumer / carer including
contact with Mental Health Services:
___________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Are you a member of a Consumer Advisory Group (CAG):

ο Yes ο No

If yes, which CAG are you a member of: _________________________________

If you are not a member of a CAG, what group of consumers / carers do you represent?

(Eg: GROW, ARAMFI, etc.) _____________________________________________________

Would you be able to attend Training Sessions as required:

ο Yes ο No

Would you be able to consult with consumers and carers to get feedback for any working
groups or committees you may be invited to participate in?

ο Yes ο No

How would you consult with other consumers / carers to ensure you were being
representative of the wider views? Please identify and give a brief explanation of how
you would consult with other consumers and carers. (Please tick and identify how you
would gather feedback)

ο Face to Face
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

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ο Attendance at CAG, or other groups (Eg: ARAFMI, GROW etc.)

ο Send regular information to consumers / carers

ο Telephone

ο Other
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

(Please tell us about your skills)

Can you use a computer? ο Yes ο No

Do you have access to a computer? ο Yes ο No

Do you have access to email? ο Yes ο No

Do you have a Drivers Licence? ο Yes ο No

Do you have access to a Private Vehicle? ο Yes ο No

What is your usual mode of transport? _____________________

Have you been on any committees or working groups for mental health services before?

ο Yes ο No

What are your areas of special interest or skills. Please list these below:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

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___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
What types of committees / working groups are you interested in sitting on or being
involved in:

ο Forensic Mental Health Sub Network– please refer to the Terms

of Reference for further information.

Please outline your previous involvement by completing the following questions. If you
require additional space please attach further details.

Question 1

If you’ve had any personal or work experience on committees or working groups, including
CAG, ARAMFI or other NGO’s. Please provide details as to which committees / groups.
Please state what your role was and what you achieved whilst on the committee / working
groups?

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Question 2

Being involved on working groups / committees will require consumers and carers to be
effective representatives, the ability to clearly communicate and provide a representative view to
the committee / working group. Please provide details of the skills and or abilities you have to
offer in this role.

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

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Question 3

We are focussed on empowering consumers and carers of mental health services. Being
involved with committees / working groups can be stressful what strategies would you be able to
utilise to help look after yourself.

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Would you like to be kept informed of future information and updates etc.

ο Yes ο No
CONFIDENTIALITY STATEMENT

I _________________________________ agree to abide by the confidentiality rules and regulations within my duties as a consumer
/ carer representative on any Queensland Health committee / working group or other group that I am appointed to.

I understand that if I am unsure on what is required of me in relation to confidentiality within this role that I will request clarification
from the chairperson of the committee / working group or the Principal Project Officer. I agree to be bound by the confidentiality
agreements that govern any committee / working group on which I am a representative.

I acknowledge and agree to be bound under Part 7 Section 62A of the Health Services Act (1991) regarding confidentiality by
employees of District Health Services which States;

‘A designated person or former designated person must not disclose to any other person, whether directly or indirectly,
any information (confidential information) acquired because of being a designated person if a person who is receiving
or has received a public sector health service could be identified from that information’

_________________________
Consumer / Carer Representative

/ / 200

If you have any queries or would like further information please contact Rick Austin on
(07) 3328 9548.
Please submit your Expression of Interest when you have completed it. Expression of
Interests will close on the 29th March 2010.
Please return to:
Rick Austin
Manager
Consumer & Carer Participation
MENTAL HEALTH BRANCH
PO Box 2368
FORTITUDE VALLEY BC QLD 4006

Office: (07) 3328 9548 Fax: (07) 3328 9126 Mobile: 0412 498 923
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Email: Rick_Austin@health.qld.gov.au

OFFICE USE ONLY

Consumer / Carer Representative Appointed Yes No

Committee /Working Group: ___________________________________________________________

___________________________________________________________
Date of Appointment _____________________

Length of Appointment 6 months 12 months 18 months 24 months Other__________

Approval By _____________________________________________________________________

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