Patient and Family Advisory Council Interest Form
Personal Information
First name
Last name
Street address
City/Town
State
Please select...
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Zip code
Best contact number
Email address
The following questions will help us get to know you better
Are you a...
Patient
Family member of a patient
Please indicate patient's full name
What WMCHealth facility did you or your loved one receive care? (
select all that apply
)
Behavioral Health Center
Bon Secours Community Hospital
Good Samaritan Hospital
HealthAlliance
Margaretville Hospital
Maria Fareri Children's Hospital
MidHudson Regional Hospital
St. Anthony Community Hospital
Westchester Medical Center
When was your care experience at WMCHealth? (
select all that apply
)
2022 to present
2019 - 2021
2018 or before
What interests you most about becoming a patient and family advisor? (
select all your interest areas
)
Providing culturally competent, patient-centered care
Developing or reviewing informational materials for patients and family members
Improving communication between patients and family members and the hospital staff?
Improving patient care areas and/or family resources
Helping educate hospital staff and clinicians
Representing WMCHealth at special events or in communications
Other issues
Please describe other issues
Please describe your aspects of your patient experience that were helpful to you or your family while in our care.
Please describe your aspects of your patient experience that were not helpful to you or your family while in our care.
Our patient and family advisors reflect the diversity of the patients and families we serve. Please share anything about yourself that you think would add to the diversity of our team of advisors.
Please briefly describe any experience you may have as an advisor, as an active volunteer, or as a public speaker.
Contact Information