Patient & Family Council Application Name Street Address City State Zip Code Phone (best contact number) E-mail What Yale Health services do you use? (check all that apply) Medical care (primary care) Specialty care (Dermatology, Orthopedics, Ophthalmology, etc.) Behavioral Health/counseling Nutritional counseling and education Nursing visits Other programs, departments, or services Please briefly introduce yourself, include your role in the University (if applicable), how you became a member of Yale Health, and how long have you been a member. Why would you like to serve as a patient partner? Are you currently or have you ever served on any committees/councils? If so, describe in what capacity? Do you have any special skills that you can offer (art, public speaking, computers, etc.)? Do you have any special interests? The council plans on evening meetings five to six times during the year (September–June). Will you be able to commit to attending at least four meetings? - Select -YesNo If you were choosing a topic of interest from the patient’s perspective, what one thing would you like the Patient & Family Council to address?