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Jeans for Genes Listening Space
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Step
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If you are under 16, please complete this with a parent/guardian.
How do you identify?:
Please select from the list
An individual with a genetic condition
A parent carer of a child with a genetic condition
A parent carer of an adult with a genetic condition
A carer of an individual with a genetic condition
A family member of an individual with a genetic condition (for example, grandparent or sibling)
A friend of an individual with a genetic condition
A stakeholder of a charity delivering services for individuals and families with a genetic condition
A health professional working with individuals and families with a genetic condition
A social care professional working with individuals and families with a genetic condition
Bereaved as a result of a genetic condition
What do you experience as an individual with a genetic condition?
What do you experience as a parent carer of a child with a genetic condition?
What do you experience as a parent carer of an adult with a genetic condition?
What do you experience as a carer of an individual with a genetic condition?
What do you experience as a family member of an individual with a genetic condition?
What do you experience as a friend of an individual person with a genetic condition?
What do you experience as a stakeholder of a charity delivering services to individuals and families with a genetic condition?
What do you experience as a health professional working with individuals and families with a genetic condition?
What do you experience as a social care professional working with individuals and families with a genetic condition?
What do you experience as an individual who has suffered a bereavement as a result of a genetic condition?
Submit
Thank you for submitting your voice. We will actively listen to all the voices shared. To help us take the conversation forward and act upon what we hear, it would be helpful for us to collect some further information. Not all the information requested is mandatory but please complete the form below as fully as you can and let us know how you would like us to communicate with you (your preferences)
Name
First
Last
Email
Contact telephone no.
Genetic condition experienced
Date of diagnosis (if applicable)
Ethnicity
Please select from the list
Asian or Asian British
Black, Black British, Caribbean or African
Mixed or multiple ethnic groups
White
Other ethnic group
Prefer not to say
Other ethnicity - please provide details
Gender
Please select from the list
Female
Male
Transgender
Non binary
Other
Prefer not to say
Other gender - please provide details
What would you like to hear about?
Please keep me updated about The Listening Space
I am happy to be contacted in relation to the insights I have shared as part of The Listening Space
I would prefer to be contacted via
*
Email
Telephone
Either email or telephone
Please do not contact me
Is there anything else you would like to tell us?
Are you under 16?
I am under 16 and a parent/guardian has read, understood and agrees to the use of my data as outlined in your privacy policy
Permission to use my data as outlined in your privacy policy
*
I agree to the use of my data as outlined in your privacy policy
Read our privacy policy here
Submit