Respite Care Assistance Application

Your Name

Relationship with Patient

Phone number

Please provide person with PD’s information below

First Name

Last Name

Street

Apt

City

County

State

Zip

Date of Birth

Phone

Neurologist’s Name

When were you diagnosed with PD

Current Major Symptoms

What type of equipment do you use?

Are you employed?

Occupation

Spouse employed?

Occupation

What is your monthly household income?

Monthly expenses?

Veterans

Please include a written confirmation of diagnosis of PD from your physician.
1. The Michigan Parkinson Foundation may require documentation of all or some of the above items.
2. I understand this request for home care is for temporary, short-term assistance.
3. Participation in this program is based on need and the availability of funds.

Upload diagnosis here

You can also send diagnosis information to Stephanie via Fax # (248) 433-1150 or email Stephaniew@parkinsonsmi.org or hard copies can be mailed to our office.

Please Review and Agree

I hereby release and hold the Michigan Parkinson Foundation, Inc. harmless from, against, and in respect of all claims, injuries, actions, demands, suits, losses, liability, or other damages that may be incurred as a result of accepting goods or services.

Please Review and Agree

I attest that, to the best of my knowledge and belief, all information in the above referenced data reported is accurate and complete.

For more information, contact Stephanie Woznak at 248-419-7170 or Stephaniew@parkinsonsmi.org.