Ovarcare Grant Application

    What is OvarCare?

    OvarCare is a financial, psycho-social and informational support program offered by Ovarcome for ovarian cancer patients in active treatment. At Ovarcome, we are inspired by the simple philosophy of support, love, and celebration of life. Ovarcoming cancer - celebrating life! We are here to help you Ovarcome ovarian cancer. Our care package helps you take care of essentials and of YOU, as you undergo treatment. OvarCare celebrates the incredibly strong and resilient Ovarcomer you are. Keep inspiring. Keep Ovarcoming!

    What does OvarCare offer?

    • Financial grant of $100

    • Psycho-Social Counseling sessions via phone by a licensed clinical social worker

    • Genetic Counseling sessions via phone by a licensed Genetic Counselor (New addition to the program)

    • $100 Gas card

    • $100 grocery card

    Who is it for? OvarCare is designed for you if you:

    • Have a diagnosis of ovarian cancer certified by an oncology healthcare provider

    • Are in active treatment, newly diagnosed or recurrent ovarian cancer patient

    • Meet our financial eligibility guidelines of 265% of the Federal Poverty Limits and are able to provide income verification documentation

    No. of people
    in household

    Gross Income

    Income Verification

    1

    $38,637

    . The first two pages of signed copy of income tax return (SSN not required)

    2

    $52,258

    - OR -

    3

    $65,879

    . Copies of your most recent pay stub, unemployment check, or public assistance benefit notification, SSI

    4

    $79,500

    - OR -

    5

    $93,121

    . If you do not have income: Provide a letter of support from friend, family member, or your healthcare team

    OvarCare Application: Steps & Guidelines

    Please apply following the guidelines provided below:

    • All sections of this application are required to be completed: including income verification documents & release consent forms. We encourage you to write to us at info@ovarcome.org with any questions prior to applying. Due to the volume of applications received, we are unable to accept incomplete applications

    • Initial consultation with a social worker at your hospital/healthcare facility to determine your eligibility to receive OvarCare based on the criteria outlined

    • You must submit a completed application to be considered for OvarCare. Patients will be selected based on provision of completed information. Unfortunately, we will not be able to review and process applications with incomplete information

    Apply in 3 steps:

    We are here to help you, your patient, or your loved one Ovarcome ovarian cancer. Please fill in the details below to complete the application.

    I hereby confirm:

    Please note: Giving and number of grants awarded at any given time depends on availability of funds. Not all completed applications may be awarded. Due to the overwhelming number of applications received, we are unable to provide status updates on individual applications via email, phone or otherwise. We try out best to award this grant to as many Ovarcomers as we can possibly help. We thank you for your understanding.

    If you wish to proceed, please complete the application. Thank you!

    Date: *

    First Name: *

    Last Name: *

    Address: *

    Phone number: *

    Email Address: *

    Date of birth: *

    Name of parent or guardian *
    If patient is a minor (under 18):

    Ethnicity: *

    CaucasianAfrican AmericanLatinoAsianOther

    PATIENT IDENTIFICATION AS WE GET TO KNOW YOU – REQUIRED STEPS:

    A recent picture is required for identification purposes (driver’s license picture not accepted). Once the application is received and reviewed for accuracy and completion, we will contact you to schedule a phone call or an in-person office visit, depending on location.

    If you need language assistance for our phone or in-person visit, we recommend you seek assistance from friends, Family, or your healthcare team representatives.

    The OvarCare Grant will be disbursed directly to you.

    Please upload your recent picture (driver’s license picture not accepted) *

    We would love to get to know you. Please provide answers to the following questions and use as much detail as you would like.

    1. How was your ovarian cancer diagnosed? What signs and symptoms did you experience? *

    2. Have you had genetic testing done? Please explain *

    3. Do you have family and friends to support you as you undergo treatment? Tell us about your support system *

    4. What do clinical trials mean to you? Have you ever considered enrolling in Clinical Trials for ovarian cancer? Tell us about it *

    5. What advice and guidance would you share with your fellow Survivors and Ovarcomers? *

    MEDICAL INFORMATION

    *** THIS SECTION MUST BE COMPLETED BY YOUR ONCOLOGY NURSE, DOCTOR, OR SOCIAL WORKER ONLY ***

    Date of diagnosis: *

    Primary cancer: *

    Current Stage: *

    New diagnosisRecurrence

    Is patient in active treatment? *

    YesNo

    If not in active treatment, indicate frequency of follow-up: *

    YearlyBi-AnnualOtherNot Applicable

    Please indicate type of treatment(s) received in past twelve months (check all that apply) *

    ChemotherapyRadiationSurgeryPalliative care

    HEALTH CARE INFORMATION

    Physician name: *

    Hospital: *

    Address: *

    Doctor/Nurse/Social Worker Name: *

    Doctor/Nurse/Social Worker Email: *

    FINANCIAL ASSISTANCE

    1. Name of patient (please print): *

    2. Do you have health insurance? *

    YesNo

    3. Are you currently employed? *

    YesNo

    4. Number of people in your household: *

    5. Please indicate the source of your family income (select all that apply): *

    Salary/compensationPensionFriend/family supportUnemployment benefitsShort-term disability

    other

    USD ($):

    Please upload your income verification document or letter of support *

    Please refer to our income eligibility criteria for the OvarCare grant as outlined in the table and review the acceptable documents for income verification.

    No. of people
    in household

    Gross Income

    Income Verification

    1

    $38,637

    . The first two pages of signed copy of income tax return (SSN not required)

    2

    $52,258

    - OR -

    3

    $65,879

    . Copies of your most recent pay stub, unemployment check, or public assistance benefit notification, SSI

    4

    $79,500

    - OR -

    5

    $93,121

    . If you do not have income: Provide a letter of support from friend, family member, or your healthcare team

    *** Annual family income information must be provided for us to process your application **

    RELEASE CONSENT FORM

    Our OvarCare program aspires to build a community of Survivors and Ovarcomers that inspire one another with stories of courage and inspiration. Our program is built on the principle that it is a support program for Survivors, by the Survivors. To that end, we periodically select a few stories of inspiration to share on our blogs or on our social media platforms.

    Please submit the release consent below. This consent also validates the picture submitted by you for the OvarCare Grant application for identification purposes.

    Release Permission: I , authorize Ovarcome to use my name, pictures, interviews, and likeness in their platforms and publications; including but not limited to video, print, and electronic media, in such manner as the non- profit organization may deem advisable for the purpose of sharing and promoting the work of Ovarcome in creating the OvarCare program, inspiring the Teal Community, and seeking funding from potential donors for program continuity. I understand that I am not entitled to reimbursement for the use of my name, photograph or participation in any and all communications developed about and by Ovarcome.

    In signing this Consent, I understand and acknowledge that: (add check marks for all)

    Date: *

    Address: *

    Email Address: *

    Psycho-Social Counseling and Genetic Counseling Sessions:

    We are here to support you through this journey of OVARCOMING. If you’d like to sign up for our Free Psycho-Social and Genetic Counseling Sessions as part of the OvarCare Grant Program, please email us at info@ovarcome.org to schedule your first appointment. We look forward to hearing from you!


    Anna CroftsPsycho-Social Counseling Sessions by Ovarcome
    Licensed Clinical Social Worker, Anna approaches her work with respect, empathy and dignity throughout the therapeutic process. Utilizing techniques from Cognitive Behavioral therapy and Dialectical Behavioral therapy, coupled with mindfulness techniques, Anna works with our Ovarcomers to help them achieve their goals. In her personal time, Anna enjoys traveling, cooking and spending time with her Dog, Po. She is here to help you as you walk this journey of Ovarcoming.

    Anna Crofts, LCSW leads our OvarCare Psycho-Social Counseling Program.


    Cathy SullivanGenetic Counseling Sessions by Ovarcome
    Cathy Sullivan is a Certified Genetic Counselor. Her special interest is in Hereditary Cancer Risk Assessment. If you have questions about genetic testing, or not sure where to begin, Cathy is happy to schedule an information session with you as part of our OvarCare Grant Program. She is here to help you in this journey of OVARCOMING.

    Cathy leads our OvarCare Genetic Counseling Program.

    Please choose the counselling services you would like: *

    Anna Crofts, Psycho-Social Counseling

    Cathy Sullivan - Genetic CounselingNot interested at this time

    If you chose psycho-social counseling services, complete your request by completing the fields below. Please add N/A in all fields if you choose to opt out: *

    Via OvarCare Counseling we are pleased to offer:

    • Up to 6 sessions of support for up to 6 months

    • Meetings by phone in any location in the U.S.

    • Supportive services to OvarCare grant recipients

    • Information, resources, referrals as needed and requested

    Our OvarCare counseling sessions are designed to provide support through the journey of Ovarcoming Ovarian Cancer and are not deemed to be psychotherapy services. Our members are ready to provide compassionate and meaningful support via active listening, providing gentle guidance in navigating the often-challenging course of diagnosis, treatment and survivorship, and in providing effective tools and resources to Ovarcome.

    Please complete the fields below to register for our counseling program:

    We are here to Ovarcome with you. Welcome to our safe and friendly space.

    This is a complimentary service as part of our OvarCare Program and is currently available in English only.

    Name:

    Date of birth:

    Email Address:

    Address:

    Do you consent to receiving text messages from your OvarCare Support Services?:

    YesNo

    Share with us the best way to reach you:

    EmailPhoneText MessageAll of the above

    Primary Phone Type:

    MobileLandline

    Please indicate your time zone:

    Eastern TimeCentral TimeMountain TimePacific Time Hawaii-Aleutian Time

    What do you wish to accomplish from these support sessions? Please share your personal goal:

    Please carefully review the acknowledgements below:

    Acknowledgement of My Consent

    BY CHECKING THIS CONSENT, I CERTIFY THAT:

    I have carefully read and consent to the terms and conditions stated herein.

    Name:

    Date:

    Please note:

    We will try our best to provide you with the assistance you need but giving will depend on the availability of funds. To that extent, an application is not a guarantee of receiving OvarCare.

    IMPORTANT NOTES

    At this time, OvarCare is administered as a one-time grant only. Please submit the application form along with the necessary verification documents for consideration. We will review the information and contact you with further details on completion and disbursement.

    Incomplete applications will not be considered. We encourage your physician/nurse/social worker to submit the application on your behalf where possible.

    Please allow at least 3-4 weeks for us to review your application from the date of submission. This timeline is dependent upon the volume of applications already received. Due to the large number of applications received, we are unable to provide status updates on each individual inquiry. All applications are processed in the order they are received. If you have additional questions on the application, please contact us at info@ovarcome.org prior to submission. We appreciate the opportunity to serve you.

    All information is strictly confidential and is for Ovarcome official use only