Patient, Client, and Partner Application Form

*First and Last Name

*City/Town of Residence

*Email Address

*Primary Phone Number

Secondary Phone Number

*What is the best way to contact you? *What is the best way to contact you? Email Phone

*What is the best time to contact you? *What is the best time to contact you? Days Evenings Weekends

*Do you have previous experience as an advisory for health or social services *Do you have previous experience as an advisory for health or social services Yes No

If you selected yes, please provide details

*How did you hear about this opportunity? *How did you hear about this opportunity? HPE OHT website HPE OHT social media HPE OHT community posters Word of mouth Other

If you selected other, please provide details

*Meetings are mostly virtual. Are you comfortable with accessing and using this technology (e.g. Zoom, Microsoft Teams)? *Meetings are mostly virtual. Are you comfortable with accessing and using this technology (e.g. Zoom, Microsoft Teams)? Yes No Some challenges

If you selected some challenges, please provide details

*What is your availability for meetings? *What is your availability for meetings? Days Evenings

Effective partnership and engagement must reflect the diversity of community we serve. To ensure that decisions being made reflect and respond to a broad range of lived experience, we welcome and encourage applications from a variety of backgrounds and perspectives. Please note that the following six questions are OPTIONAL.

I identify as I identify as Francophone Indigenous, First Nations, Métis, or Inuit A racialized or visible minority Other Prefer not to say

If you selected other, please provide details

My preferred gender pronouns are My preferred gender pronouns are He/Him She/Her They/Them Other Prefer not to say

If you selected other, please provide details

I identify as part of the 2SLGBTQIA+ community I identify as part of the 2SLGBTQIA+ community Yes No Prefer not to say

I identify as low income I identify as low income Yes No Prefer not to say

I identify as having a disability I identify as having a disability Yes No Prefer not to say

My education level is My education level is Grade school High school Undergraduate degree Graduate degree Other Prefer not to say

If you selected other, please provide details

Which services do you (or your family member/the person you care for) have experience accessing? (Please check all that apply) Which services do you (or your family member/the person you care for) have experience accessing? (Please check all that apply) Family Doctor or Nurse Practitioner Geriatric Services (e.g., Algoma Geriatric Clinic) Community Care (e.g., Alzheimer Society, Memory Clinic) Emergency Department Long Term Care Home Care Social Services Mental Health and Addictions Services Other

If you selected other, please provide details

How frequently do you (or your family member/the person you care for) access health and/or social services? How frequently do you (or your family member/the person you care for) access health and/or social services? More than 1-2 times per month 1-2 times per month Once every 6 months Once a year or less Other

If you selected other, please provide details

Conditions of Application: I understand that I am not guaranteed a seat on the HPE OHT PCPC I understand that I may withdraw my application at any time .

*Please type your name

*Please type the date