Forms

Required fields are marked with asterisks (*)

Expression of Interest Form

Thank you for your interest in Headwaters Patient Family Advisor Partnership.

Preferred Method of Contact
 
Are you one of the following
 
Languages Spoken
 
Do you have lived experience at Headwaters in the last 3 years?
 
What areas of service are you interested in? Select all that apply
 
Are you comfortable sharing your lived experience with the Patient & Family Advisory Partnership and/or other project/program groups in order to learn from that experience and make improvements? (select one)
 
Are you currently a volunteer at Headwaters?
 
Do you have access to a computer and email?
 
Have you participated in any patient and family engagement activities in the past?
 
Are you currently or have you ever been involved in a legal challenge between you/your family and a hospital?
 
Please specify the time when you are most available to attend group meetings, be involved in projects/committees:
 
How did you hear about the Patient & Family Advisory role/opportunity?
Please confirm that you understand and agree with the following
 



Accredited with Exemplary StandingWe are dedicated to safe, high-quality care, Headwaters is proudly accredited with Exemplary Standing.

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