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Patient Family Advisory Council Application Form
Your name
Street Address
City
State
Zip Code
Email
Phone
Contact preference (select one)
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Email
Phone
Are you a… (select one)
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Patient
Family member of a patient
When was your care experience with Imagine Pediatrics? (Check all that apply)
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January to June 2023
June 2023 to present
What language(s) do you speak in your home?
We recognize that our Patient Family Advisory Council members have busy lives. How much time are you able to
commit each month? (Check one)
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Less than 1 hour a month
1–3 hours a month
Are you available to serve as an Advisor for at least 1 to 2 years? (You can still be an Advisor if you answer “no.”)
Select your option
Yes
No
How do you want to help? I want to: (Check all of your interest areas)
Serve as a member of the Patient Family Advisory Council. Potential PFAC members should be ready to commit to serving on the Council for at least 1 to 2 years. The Advisory Council meets once a month for 1 ½ to 2 hours.
Help develop or review informational materials for patients and families.
Help improve patient safety and the prevention of medical errors.
Help improve the patient and family role in care decision-making.
Help improve the Imagine Pediatrics mobile app experience.
Help educate or train staff, doctors, nurses, and others.
Provide input to improve the start-up process with Imagine Pediatrics.
Give feedback on new services Imagine Pediatrics is considering.
Help improve transitions in care (like discharge from hospital to home).
Why do you want to become a Patient Family Advisory Council member?
Please briefly describe any experience you may have as an advisor, as an active volunteer, and/or as a public speaker.
Please describe any specific things that the Imagine Pediatrics team did or said while your child was in our care that were most helpful to your child and/or to you.
Please describe anything the Imagine Pediatrics team could have done to be more helpful to your child and/or to you while in our care.
What would you say we could do differently to make life a little easier for other children and their families?
Our Patient Family Advisory Council members 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 Counselors.
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