Volunteer | Become and Advocate

Become an Advocate

Hearts & Minds Patient Advocacy INC

VOLUNTEER APPLICATION FORM

Mission Statement: We provide support and advocacy for patients and their families as they encounter health obstacles.

Vision Statement: Each patient and/or family member feels adequately supported and heard during their health endeavors improving their healthcare experience.

Section 1 | Personal Information

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Contact Name

Emergency Contact Phone

Section 2 | Availability and Commitment

Please indicate your availability and desired commitment level.

Desired Start Date:

How many hours per week are you willing to commit? (Minimum 4 hours/week recommended)

Please check the times/days you are generally available:

Weekday Mornings (9am - 12pm)

Weekday Afternoons (12pm - 4pm)

Weekday Evenings (4pm - 7pm)

Weekends (Anytime)

Are you able to provide your own reliable transportation to client appointments or meetings? (Check box for YES)

Section 3: Skills and Experience

Our clients include the elderly, critically ill, disabled persons, and low-income families, requiring dedicated support in care coordination, resource navigation, and emotional support.

Please check any of the following areas where you have relevant professional or personal experience:

Patient Advocacy / Caregiving

Social Work / Counseling

Healthcare (Nursing, Administration, etc.)

Resource Navigation (Medicaid, government programs)

Financial Management / Planning (Relevant to the critically ill)

Legal or Will Planning Support

Administrative/Clerical Tasks

Translation/Interpreting (If yes, please specify language: ______)

Describe any previous experience you have working with our target populations:

Section 4: Cognitive Listening and Values Alignment

Our services require "cognitive listening"—the ability to deeply process and synthesize complex, stressful information while providing unwavering emotional support.

A patient tells you their doctor explained a new treatment, but they look confused and only remember the negative side effects. What is your primary response?

In your view, why is it vital for a patient advocate to focus on the client's emotional state (their "Hearts & Minds") as much as their medical facts? (Please be candid, this helps us assess alignment with our Vision.)

Are you comfortable assisting clients with sensitive and private tasks, such as those related to financial management, will planning, or end-of-life care? (Check box for YES)

Section 5: Agreement and Signature

I understand that as a volunteer for Hearts & Minds Patient Advocacy INC, I may be exposed to confidential and protected health information (PHI). I agree to maintain the strict confidentiality of all client information. I understand that a background check may be required for this position.