Cherie Levien Quality of Life Respite Fund Application - October 2022

The Cherie Levien Quality of Life Fund was established to provide financial support for hiring professional home care services for those living with or caring for someone diagnosed with PSP, CBD, or MSA. Research indicates that even temporary or intermittent relief of caregiving demands ("respite") can help reduce stress and improve the quality of day-to-day life for carepartners as well as for the person who is living with the disease.

The fund provides grants for 60 hours of in-home care services (up to $35/hr) by a home care agency chosen by the awardee. You will not need to pay directly; the home care agency will be paid directly by CurePSP.

For any inquiries about the application or the fund, please contact Joanna Teters at teters@curepsp.org

Patient Information

Question Title

* 1. Contact information for patient

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address (if applicable)

Phone Number

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* 2. Patient date of birth (MM/DD/YYY)

Question Title

* 3. Gender of patient

Male

Female

Non-binary

Prefer not to respond

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* 4. Race/ethnicity of patient

Asian

Black or African American

Hawaiian or Other Pacific Islander

Native American, Indigenous, or Alaska Native

White

Prefer not to respond

Other (please specify)

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* 5. Is the patient of Hispanic or Latino origin?

Yes

Prefer not to respond

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* 6. Marital status of patient

Single

Married

In a relationship

Widowed

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* 7. Is the patient currently receiving care from a primary family carepartner?

Yes, the patient is currently receiving care from a primary family carepartner

No, the patient is not currently receiving care from a primary family carepartner