Phase I Application. Please make sure that you are completing the correct application!

Phase I Application Please make sure that you are completing the correct application! P h a s e I Ap p l i c a t i o n is for clinics/organizations that do not currently provide either SPEAK OUT! or The LOUD Crowd. P h a s e I I Ap p l i c a t i o n is for clinics/organizations that currently provide SPEAK OUT! only and are now ready to implement The LOUD Crowd. P h a s e I II Ap p l i c a t i o n is for clinics/organizations that currently provide both SPEAK OUT! and The LOUD Crowd. Applications are due by March 2, 2018. Please email your application to grants@parkinsonvoiceproject.org or mail your application to: Parkinson Voice Project c/o Grant Program 646 North Coit Road, Suite 2250 Richardson, TX 75080

1 Phase I Application Phase I clinics/organizations will be considered for all of the grant opportunities listed below; however, every clinic/organization may not receive each item. From the list below, please prioritize the items from most important to least important to your clinic/organization. Place a number on the line to the left of each item (1 = most important; 8 = least important). Please note that all Phase I clinics/organizations must attend a 3½ day conference at Parkinson Voice Project on June 20-23, 2018 to be considered for a grant. The conference includes training on these topics: SPEAK OUT!, The LOUD Crowd, Good To Great Business Principles, Volunteer Engagement, Fundraising Strategies, Pay It Forward, and Parkinson s Singing Success. Since this conference is mandatory for all Phase I grant recipients, the number 1 has already been placed on the appropriate line. 1 Invitations for two representatives (one speech-language pathologist and one administrator) to attend a 3½ day conference (June 20 23, 2018) at Parkinson Voice Project. If two entities are collaborating, invitations may be provided to four representatives. Reimbursement of roundtrip airfare for representatives attending the 3½ day conference at Parkinson Voice Project Reimbursement of hotel accommodations for representatives attending the 3½ day conference at Parkinson Voice Project LOUD Crowd Workbooks (up to 12) Sing With INTENT! Songbooks (up to 12) Six free registrations for speech-language pathologists to take continuing education courses offered through Parkinson Voice Project s Parkinson s Lecture Series. These courses provide additional education on critical topics related to Parkinson s. Each course is offered for.15 ASHA CEUs. Marketing and educational materials Up to $1,000 to help fund The LOUD Crowd

2 Read each statement below carefully and affirm by checking the box on the left that your clinic/organization meets each requirement. These requirements must be met in order to qualify for a grant. Our clinic/organization is prepared to provide both SPEAK OUT! and The LOUD Crowd. Our clinic/organization has a minimum of two speech-language pathologists who will be assigned to our SPEAK OUT! and LOUD Crowd program (Note: Parkinson Voice Project understands that these speechlanguage pathologists may also be working with other patient populations). Our clinic/organization understands that a LOUD Crowd group is only made up of individuals diagnosed with Parkinson s or Parkinson s-plus Syndromes. In other words, a LOUD Crowd group is not made up of patients with varying diagnoses. Our clinic/organization understands that a LOUD Crowd group is for patients who have completed, or are in the process of completing, SPEAK OUT! and that the group s purpose is to help patients maintain the improvements made during SPEAK OUT! therapy. The LOUD Crowd is not a traditional Parkinson s support group. Our group speech therapy room is consistently available on the same day of the week and at the same time of day. Our clinic/organization will provide a safe environment for our Parkinson s patients that includes accessible parking, handicap restrooms, first aid supplies, and sturdy tables and chairs (no rolling chairs). Our clinic/organization will provide water to our patients during both SPEAK OUT! and The LOUD Crowd therapy sessions. Our clinic/organization will appoint a minimum of one volunteer or aide trained in Parkinson s-specific mobility/ambulation strategies to assist LOUD Crowd members as they arrive and leave group therapy.

3 Our clinic/organization has the support of administration to implement both SPEAK OUT! and The LOUD Crowd (Note: This application requires signatures of both the primary speech-language pathologist who will be assigned to the program and the administrator responsible for the speechlanguage pathology services. If two entities are collaborating to provide SPEAK OUT! and The LOUD Crowd, then the application will require signatures from both entities). Two representatives from our clinic/organization (primary speechlanguage pathologist and administrator) are available to travel to Dallas, Texas on June 20 23, 2018 for a 3½ day conference at Parkinson Voice Project (Note: If two entities are collaborating to provide SPEAK OUT! and The LOUD Crowd, then representatives from both entities must attend the conference).

4 Please note that every question on this application must be answered in order to be considered for a grant. Indicate N/A for items that do not apply to your clinic/organization. The first part of the application pertains to SPEAK OUT!, while the second part pertains to The LOUD Crowd. If two entities will be collaborating to provide this two-part program, each should complete the appropriate portion of the application. SPEAK OUT! General Information About the Clinic or Organization that Will Provide SPEAK OUT! Name of clinic/organization Street address Suite City State Zip Phone number Website Name and credentials of administrator Title of administrator Administrator s phone number

5 Administrator s email Name of primary speech-language pathologist (include ASHA credentials) Primary speech-language pathologist s phone number Primary speech-language pathologist s email Contact Information for Patients If you are selected for a grant, what information do patients need in order to schedule an appointment with your clinic/organization? This information will be posted on Parkinson Voice Project s website. Name of clinic/organization Street address Suite City State Zip Phone number Website

6 T e l l U s Ab o u t Y o u r C linical Setting Select your type of clinical setting (Note: If SPEAK OUT! will be provided in more than one clinical setting, please select all that apply): Inpatient rehabilitation Outpatient rehabilitation Skilled nursing Private practice University speech therapy clinic Home health Nonprofit Parkinson s organization Other If other, please describe. Does your clinic/organization currently treat individuals with Parkinson s? If the answer is yes, how many individuals with Parkinson s do you treat per month? What treatment methods are you currently utilizing to treat this patient population?

7 How is your clinic/organization currently reimbursed for adult speechlanguage therapy evaluations and treatment? Medicare Private insurance Donation-based system Other If other, please describe. What is your clinic/organization s protocol when encountering a patient who does not have insurance or is unable to pay for individual speech therapy? Do your speech-language pathologists have daily productivity standards that they must meet? Please describe these expectations.

8 How long is a typical speech therapy session at your clinic? 30 minutes 45 minutes 60 minutes Other: Using audio and video recordings during SPEAK OUT! therapy has proven to be a valuable tool to demonstrate treatment progress to patients/family members and to educate physicians and the community about the benefits of the program. Will your clinic/organization have the ability to audio and video record your patients? Yes No The SPEAK OUT! protocol requires that patients either attend a Parkinson s Information Session held at your clinic/organization or view the online version of this session on Parkinson Voice Project s website (a 14- minute video). Will your clinic/organization conduct its own Parkinson s Information Sessions or do you anticipate referring patients to Parkinson Voice Project s website to fulfill this part of the treatment protocol?

9 Please provide information about the speech-language pathologists who will be providing SPEAK OUT! Name of speech-language pathologist (including ASHA credentials) Years of experience treating individuals with Parkinson s Full-time employee, part-time employee, contractor, other? Will you have speech-language pathology graduate students providing SPEAK OUT! therapy? Yes No Parkinson Voice Project does not require graduate students interning in a clinic to complete formal SPEAK OUT! training, as long as their clinical supervisor(s) have completed the course. How will you ensure that graduate students are administering SPEAK OUT! according to protocol? What percent of the time will your graduate students be supervised when conducting SPEAK OUT! therapy? %

10 For university speech therapy clinics: Please describe when your SPEAK OUT! program will be in session throughout the year. Describe referral sources for your SPEAK OUT! program. Do you have movement disorder specialists in your community? Yes No Please provide information about your relationship with movement disorder specialists in your community. Do they currently refer patients to your clinic/organization? Do you collaborate on a regular basis?

11 Does your clinic/organization provide other treatments/services to your Parkinson s community (e.g. support groups, physical therapy, care partner groups)? Please describe. Please describe the services that are available to your Parkinson s community outside of your clinic/organization (e.g. Dance for PD, Rock Steady Boxing). How will you educate your Parkinson s community about SPEAK OUT!?

12 W h a t M o t i va t e s Y o u r Clinic/Organiz ation? How did you hear about Parkinson Voice Project? Why is your clinic/organization interested in offering SPEAK OUT! to your Parkinson s community? Does your clinic/organization have plans to conduct research related to SPEAK OUT!? Please describe.

13 In one year, what benefits/advantages do you hope will occur for your clinic/organization as a result of implementing SPEAK OUT!? Please describe. Describe any concerns you may have in terms of implementing SPEAK OUT!. Do you have additional information you would like to share with Parkinson Voice Project?

14 I have read the requirements listed on pages 2 and 3 and have reviewed the SPEAK OUT! section. I attest that the information provided is accurate and complete. Administrator s signature (SPEAK OUT! ) Print name Date Primary speech-language pathologist s signature (SPEAK OUT! ) Print name Date

15 The LOUD Crowd General Information About the Clinic or Organization that Will Provide The LOUD Crowd Name of clinic/organization Street address Suite City State Zip Phone number Website Name and credentials of administrator Title of administrator Administrator s phone number Administrator s email Name of primary speech-language pathologist (include ASHA credentials) Primary speech-language pathologist s phone number Primary speech-language pathologist s email

16 T e l l U s Ab o u t Y o u r C linical Setting Where will your LOUD Crowd group(s) be held? How will your patients transition from SPEAK OUT! to The LOUD Crowd? What will your procedure be? Once a SPEAK OUT! and LOUD Crowd program is initiated, it can grow very rapidly. Is your clinic/organization prepared to offer more than one weekly LOUD Crowd group if the caseload warrants? Yes No

17 Will you invite individuals with Parkinson s who have completed SPEAK OUT! throughout your area to participate in your LOUD Crowd program? Please explain your anticipated protocol. For example, Parkinson Voice Project invites any person with Parkinson s who has completed SPEAK OUT! to participate in its LOUD Crowd program; however, patients must first complete a speech evaluation with our clinic. Appropriate recommendations are then made in terms of additional therapy or transition into The LOUD Crowd. How do you plan to fund your LOUD Crowd program? Please provide information about the speech-language pathologists who will be conducting your LOUD Crowd group(s). Name of speech-language pathologist (including ASHA credentials) Years of experience treating individuals with Parkinson s Full-time employee, part-time employee, contractor, other?

18 How do you plan to communicate information with your LOUD Crowd members (e.g. reminders and other pertinent information)? Will you have speech-language pathology graduate students conducting LOUD Crowd groups? Yes No Parkinson Voice Project does not require that graduate students interning in a clinic complete formal SPEAK OUT! /LOUD Crowd training, as long as their clinical supervisor(s) have completed the course. How will you ensure that graduate students are administering The LOUD Crowd according to protocol? What percent of the time will your graduate students be supervised when conducting LOUD Crowd groups? %

19 For university speech therapy clinics: Please describe when your LOUD Crowd groups will be in session throughout the year. Does your clinic/organization currently conduct any other speech therapy groups (e.g. aphasia groups)? Yes No If you answered yes to the above question, please describe the speech therapy groups that your clinic/organization currently conducts, along with any challenges you have encountered in terms of offering group speech therapy. Does your clinic/organization provide other treatments/services to your Parkinson s community (e.g. support groups, physical therapy, care partner groups)? Please describe.

20 Does your clinic/organization plan to provide a singing group as part of your LOUD Crowd program? Please describe who will lead the singing group and what resources you have available for your music program. How will you educate your Parkinson s community about The LOUD Crowd? W h a t M o t i va t e s Y o u r Clinic/Organiz ation? How did you hear about Parkinson Voice Project?

21 What is motivating your clinic/organization to offer a weekly LOUD Crowd group(s)? Please explain. In one year, what benefits/advantages do you hope will occur for your clinic/organization as a result of implementing The LOUD Crowd? Please describe. Describe any concerns you may have in terms of implementing The LOUD Crowd. Do you have additional information you would like to share with Parkinson Voice Project?

22 I have read the requirements listed on pages 2 and 3 and have reviewed The LOUD Crowd section. I attest that the information provided is accurate and complete. Administrator s signature (The LOUD Crowd ) Print name Date Primary speech-language pathologist s signature (The LOUD Crowd ) Print name Date Questions? grants@parkinsonvoiceproject.org (469) 375-6500