Application Form.

Subsidized ADHD Screeningadmin2025-10-05T14:19:09+00:00

Thank you for your interest in NVOX’s Subsidized ADHD Diagnostic Program. This program provides a comprehensive online assessment and a personalized report, offered either free of charge or at a subsidized rate for families who may not otherwise be able to afford a private evaluation.

We currently offer free assessments on an ongoing basis. If selected, you’ll receive a comprehensive report and a one-on-one consultation with a licensed psychologist in your state. The program is designed for children and teens ages 8 to 18.

This is a very short form – it should only take a few minutes to complete. Please fill it out to apply.

First Name *

Last Name

Email Address *

City *

State/Province *

Phone

Financial Eligibility

This program is intended for families facing financial limitations. Please answer the following:

Does your child qualify for free or reduced-price school meals? *YesNo

Do you currently receive any government assistance (e.g., SNAP, Medicaid)? *YesNo

Would you consider your current financial situation a barrier to accessing ADHD diagnostics privately? *YesNo

About Your Child

Child’s Birthday *

Has your child shown any of the following? (Check all that apply) *(Check all that apply)Trouble concentratingImpulsivityDifficulty following instructionsForgetfulnessRestlessness or hyperactivity

Has a teacher ever expressed concerns about your child’s learning or attention? *YesNo

Can we contact your child’s teacher to complete a short questionnaire? *YesNoMaybe

Has your child ever been evaluated for ADHD or a learning disability? *YesNo

How much do these difficulties impact your child’s academic or social life? *SignificantModerateMinimal

What motivates you to seek an ADHD screening for your child? *

If your child is selected, will you commit to participating in the process and using the results to support them? *YesNoMaybe

Consent *

I understand and agree to participate in this process if selected.

All information will be kept confidential and used only for the purpose of this screening.

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