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? * Yes No 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? * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
