PFAC Survey

BeHealthy Partnership Patient and Family Advisory Council Member Application

Time to complete this application: 10 min
Name
Address (Street, City, State & Zip Code)
Date of Birth

MonthDayYear
Date
Email Address
BeHealthy Member ID Number
What language are you most comfortable speaking?

EnglishSpanishOther
If you are a family member what is your relationship to the member?

Parent/GuardianChildSpouseSiblingAunt/UncleGrandparentGrandchildOther
Are you, or a family member, a patient at any of the below health centers or primary care offices?

Baystate Primary Care – Feeding HillsBaystate Primary Care – LongmeadowBaystate Primary Care – PalmerBrightwood Health CenterBaystate General PediatricsHigh Street Health CenterMason Square Neighborhood Health CenterNorthern Edge Adult and Pediatric MedicineBaystate Primary Care – WestfieldWest Side Adult MedicineBaystate Medical Practices Adult Medicine – WilbrahamQuabbin Adult Medicine – BelchertownBaystate Family Medicine – GreenfieldBaystate Family MedicineBaystate Medical Practices Adult Medicine – South HadleyQuabbin Pediatrics Medicine
Have you been a volunteer in the past? (Select all that apply)

Another Patient Family Advisory CouncilAnother advisory board, committee, or councilVolunteer for your church/faith organizationA school-based committee (Parent Teacher Organization, booster club, etc.)Board of Directors or TrusteesOther
How did you hear about the BeHealthy Partnership(BHP) Patient and Family Advisory Council?

BHP website or social mediaInternetSocial MediaYour health center/staffBHP directlyOther
Why do you want to serve on the PFAC?
Thank You! We thank you for your interest and look forward to your continued involvement.
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BeHealthy Partnership Patient and Family Advisory Council Member Application

Time to complete this application: 10 min