Patient Family Advisor Application

Personal Information

The Patient and Family Engagement (PFE) Department is a system wide approach to ensure the voice of our patients and families are incorporated in a variety of ways. As an advisor you would provide your time as a mentor, reviewing patient materials, completing surveys, attending meetings with leadership and/or sharing your experience.

Before becoming you become an advisor for Texas Children's you will need to complete minimum requirements depending on support Texas Children's. Advisors will need to complete an interview process, application, health screening (with vaccinations), background check, orientation, and required training before you are eligible to participate in advisory activities. As part of joining our team, we will ask that you serve a minimum of one year.

Name

* First Name

* Middle Initial (Use 'n/a' if you don't have a middle initial)

* Last Name

Preferred Name

Address

Street Address

City

State

Zip Code

Date of Birth & Gender

Gender

DOB (month)

* DOB (day)

Driver's License Number

Contact Information

Home Phone Number

Cell Phone Number

Email Address

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship

Additional Information

Diversity is important to Texas Children's and the Patient and Family Engagement department. We strive to have our advisors represent our patient population to ensure we have balanced feedback from all of our patients and families. Please tell us about you and your family.

Are you a TCH or Baylor employee?  If yes, our team will connect with you regarding Texas Children's employee volunteer policy.

Are you willing to complete the necessary health clearance requirements to participate in onsite activities, or would you prefer to fulfill your role virtually?

Current Employer

What languages do you speak? (select all that apply)

How would you describe yourself?

Any additional information you would like to provide about yourself? (for example: What are your goals for volunteering?)

Engagement Experience

How did you hear about the Patient & Family Engagement program?

Which Texas Children's location(s) do you receive services? (check all that apply)

Austin Campus

Center for Children and Women

Health Plan

Medical Center

Pavilion for Women

Texas Children's Pediatrics

Specialty Care Clinic(s)

Urgent Care

West Campus

The Woodlands

What is your role when receiving services at Texas Children's? (check all that apply)

Parent

Patient 18 and older

Patient 17 and younger

Guardian/Caregiver

Grandparent

Foster Parent

Other

If applying as a family advisor, please provide name(s) of your children and date of birth who receive services at Texas Children's

What type of health coverage do you/your child have when receiving care at Texas Children's? (check all that apply)

Private (employer or direct purchase)

Texas Children's Health Plan

Other Public (Medicaid Medicare)

Government (VA)

Self Pay

Uninsured

Other/Unknown

Prefer not to answer

What area(s) are you interested in serving?

Advisory Committee

Bereavement / Palliative Care

Experience Story Sharing (verbal or written)

Material Review / Patient Education

Parent Mentoring / Support Programs

Process Improvement - Quality Safety Experience

Simulation

Staff Education / Trainings / Presentations

Surveys

Unsure

Virtual Engagement

References

Reference #1

Name

Email Address

Phone Number

Reference #2

Name

Email Address

Phone Number

Family Advisor Biography

We would love to know al ittle more about you and your interest in being an advisor at Texas Children's.

We would love to know you better! Please provide a brief background about yourself and what motivates you to serve as a Family Advisor

Background about yourself/family and experience with Texas Children's

Motivation to participate as an advisor

Other community engagement committees

Conclusion

Have you ever been convicted of a misdemeanor?

Have you ever been convicted of a felony?

Advisors must be at least 18 years of age and make a commitment to participate for a minimum of 1 year. Prospective advisors are strongly encouraged to consider the time commitment, consistency, and dedication necessary to make the patient and family advisor experience beneficial to both you and to the patients, families, departments and Hospital staff we serve.

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