Toronto Stroke Networks Patient and Family Advisor - Application Form

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* 1. Contact Information

Full Name

Address

City/Town

Province

Postal Code

Email Address

Preferred Phone Number

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* 2. Which is the best way to contact you?

Call my preferred phone number

Send me an email

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* 3. What is the best time for us to contact you?

Morning

Afternoon

Evening

The following questions will help us get to know you better....

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* 4. I am a....

patient/ person with stroke

family member of a patient/ person with stroke

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* 5. When did you or your family member have a stroke?

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* 6. How much time are you able to commit to being a patient and family advisor?

Less than 1 hour per month

1-3 hours per month

4-5 hours per month

Other (please specify)

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* 7. How long are you able to serve as an advisor?

less than 1 year

1-2 years

More than 2 years

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* 8. How do you want to help as an Advisor? (click all that apply)

Serving as a member of the Patient and Family Advisory Committee (PFAC)

Participating on short term working groups

Helping develop or review educational resources

Providing feedback on and helping to improve programs and clinical practices

Attending focus groups

Sharing your stroke experience with health care providers or others

Speaking at health care or community events

Providing peer support to others who have had a stroke
(note: You will be referred to the March of Dimes After Stroke Program Volunteer Coordinator)

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* 9. Most PFAC meetings take place on weekdays during business hours (between 9am to 4pm). Are you available to join meetings during these times?

Yes

Personal information contained on this form is collected pursuant to the Public Hospitals Act and the Freedom of Information and Protection of Privacy Act and will be used for the purpose of the Patient and Family Experience Advisory selection and placement for the Toronto Stroke Networks. We will not share this information otherwise without permission from the applicant/guardian. https://www.tostroke.com