Patient and Family Advisory Council

Thank you for your interest in volunteering as a patient and family advisor


 
Name:  *
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City:  *
State: 
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 Phone  Email We hope to find volunteers who reflect the diverse population of our patients and families who use the hospital and its clinics. Please answer the following questions regarding your experience at Newton-Wellesley Hospital (NWH). 
I am or have been: 
 A family member of a patient 
 A patient 
 Both patient and family member 
Within the past two years, my care at NWH included: 
 Both inpatient and outpatient 
 Clinic visit (outpatient) 
 Emergency Department care 
 Hospitalization (inpatient) 
Within the past two years, what type of care did you or your family members receive at NWH? 
 Cancer Care  Cardiology 
 Emergency Department  General Surgery 
 GI  Intensive Care Unit 
 Mental Health  Neurology 
 OB/GYN Neonatal Intensive Care Unit  Orthopedic 
 Other  Pediatrics 
 Primary Care  Rehabilitation Services (OT/PT/speech) 
If you answered Other, please specify: 
We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor (please check one)?
(Minimum is two hours, six times throughout the year) 
 Less than one hour per month 
 More than four hours per month 
 One to two hours per month 
 Three to four hours per month 
Please tell us why you are interested in serving as a patient and family advisor and why you feel you would be a good representative for other patients and families. 
When receiving health care, what part of your experience is most important? 
Briefly describe any experience you have had as an advisor or volunteer. 
If you think you may have any conflicts of interest we should consider when reviewing your application, please describe. 
If we are not able to accommodate you as a patient/family advisor at this time, would you be interested in learning about other volunteer opportunities at the hospital? 
 Yes  No