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KNOWAutism Foundation Autism Diagnostic Assessment Financial Assistance Program
The Autism Diagnostic Assistance Program provides scholarships for diagnostic testing to financially disadvantaged families with children between the ages of 18 months and 18 years old. We will provide financial assistance ranging from $500 - $1,500 per child to help pay for the cost of diagnostic testing for autism spectrum disorder. Awards are one time only. The exact award amount is based on demonstrated financial need and available funds. Applicants will be notified via email within 6-8 weeks of submitting their application if they have been selected to receive a scholarship.
Eligibility Requirements
The family must reside in the Greater Houston Area (defined as living in one of the following counties: Austin, Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller), demonstrate a need for financial assistance, and provide relevant information for the committee to review. The individual being tested must be at least 18 months of age and not older than 18 years of age. Review Process: The Program Committee reviews applications on a rolling basis and selects a limited number of applicants to receive financial support scholarships. A member of the committee may contact you to request additional information or documentation, if needed. All applications and documentation provided remain confidential during the review process. If you are selected to receive a financial support scholarship, a committee member will contact you at the e-mail provided on your application. If you are seeking assistance for more than one dependent, a separate application must be submitted for each individual. The KNOWAutism Foundation reserves the right to provide a diagnostic assessment with a provider of our choosing. Award Acceptance Requirements: If you are selected to receive financial assistance, you will receive an award letter and an acceptance agreement, which must be read, signed, and returned within sixty (60) days. You will need to provide an invoice for the program/services you are requesting assistance for, a thank you note, a photo of the scholarship recipient, a :30 video of the scholarship recipient, and sign a release granting the KNOWAutism Foundation permission to use your dependent's first name, photographic likeness, or video likeness in its publications, social media, website, educational training, fundraising materials, and/or other media prior to any payments being made on the scholarship recipient's behalf. Please note: Payments are made directly to the service/program providers on behalf of the scholarship recipient.
Is the scholarship applicant a U.S. citizen? Please note we are only able to fund awards for U.S. citizens at this time.
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Please Select
Yes
No
Do you reside in the Greater Houston Area (Defined as residing in one of the following 9 counties: Austin, Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller)
*
Please Select
Yes
No
Date of Application:
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Month
-
Day
Year
Date
Parent/Guardian's Name (completing this application):
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First Name
Last Name
Parent/Guardian #2's Name:
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First Name
Last Name
Parent/Guardian #1 Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #2 Address (if different from Parent #1):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian email:
*
example@example.com
Parent/Guardian #2 email:
example@example.com
Parent/Guardian #1 Cell Phone Number:
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Please enter a valid phone number.
Alternate Phone Number:
Please enter a valid phone number.
Child's Name:
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First Name
Middle Name
Last Name
Child's Date of Birth:
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Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2026
2025
2024
2023
2022
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2020
2019
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Year
Child's sex:
Please Select
Male
Female
Briefly describe the child and why you are seeking a clinical evaluation for autism spectrum disorder (ASD). Please include any information that you believe would be helpful for our consideration.
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Child's current medical diagnoses (if any):
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Is your child verbal or non verbal?
Please Select
Verbal
Non verbal
I do not know
Has anyone at your child's school completed any type of assessment or suggested you should have your child tested?
*
Please Select
Yes
No
My child is too young to be enrolled in school
I home school my child
If yes, please provide details.
Diagnostic Provider Name (if you have identified one):
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Facility Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Contact Name:
Facility Phone Number:
Please enter a valid phone number.
Facility Contact email:
example@example.com
Do you already have an appointment scheduled with a provider for an assessment?
*
Please Select
Yes
No
If yes, when is the scheduled appointment? If you do not have one, type N/A.
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Parent/Guardian #1's marital status:
*
Please Select
Married
Living Separately, but legally married
Domestic Partnership
Divorced
Widowed
Never married
Parent/Guardian #2's marital status:
*
Please Select
Married
Living Separately, but legally married
Domestic Partnership
Divorced
Widowed
Never married
Not Applicable
If parent/guardian #1 is unmarried to parent/guardian #2, who is authorized to make medical decisions about the child? *A certified court document outlining the custodial arrangement is required with this application.
*
Please Select
Joint Managing Conservatorship
Sole Managing Conservatorship
Third Party Custody
Other
Not applicable
If "other", please explain:
Parent #1: Number of dependents (defined as a person you claim on your tax return as a legal dependent):
*
Parent #2: Number of dependents (defined as a person you claim on your tax return as a legal dependent):
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Parent/Guardian #1 Gross Annual Income (Household):
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Parent/Guardian #2 Gross Annual Income (Household):
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Please list all sources of income and amounts. This includes child support, spousal maintenance, SSI, Disability Benefits, financial assistance from family members, friends, place of worship, etc.
*
What is your current living situation?
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Please Select
Own
Rent
Live with family
Live with someone other than family
Government Subsidized Housing
Other
If other, please explain.
If the parent/guardian applying for this scholarship has more than one dependent, do any of the other dependents have special needs? If so, please list their name(s), age(s), and diagnoses.
*
Is the child you're requesting assistance for covered by medical insurance (not including Medicaid)?
*
Please Select
Yes
No
If yes, what type of medical insurance plan is the child covered under (not including Medicaid)?
*
Please Select
PPO through Employer
HMO through employer
HMO through Marketplace
Other
None
If yes, is the provider you are seeking assistance with in network?
*
If yes, what is your remaining out of pocket for the year?
Name of insurance company (a copy of the front and back of the insurance card is required with this application):
*
Primary insured's Name:
Deductible:
Annual in network out of pocket max:
Annual out of network out of pocket max:
Is your child currently enrolled with Medicaid in Texas?
*
Please Select
Yes
No
If yes, what plan is your child currently enrolled in?
*
Please Select
Texas STAR (typically low income)
STAR Kids (Children and adults 20 years and younger who have disabilities)
STAR + PLUS (Adults with disabilities or are 65 or older)
STAR Health
Traditional Medicaid (available only if not enrolled STAR, STAR+PLUS, STAR Kids, or STAR Health)\
Not enrolled in Medicaid
Have you applied for financial aid, scholarships, grants, or other financial assistance to cover any part of the requested diagnostic assessment?
*
Please Select
Yes
No
If yes, please include the names of the entities from which you have applied, the date, and the amount of assistance requested. If you have been approved, please provide details of the award. If not, please enter N/A:
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Grant amount requesting:
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Describe your particular financial situation and why you are seeking financial assistance. The more details, the better.
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Has the child previously received a grant from the KNOWAutism Foundation?
*
Please Select
Yes
No
If yes, list year(s) and amount(s) awarded:
How did you hear about the KNOWAutism Foundation’s grants? Please be specific.
*
By signing this form, you certify that all answers provided are true and complete to the best of your knowledge. I understand that incomplete applications will not be accepted or considered. I understand knowingly providing false information will disqualify my family from consideration for all current and future grants offered by the KNOWAutism Foundation. I grant permission for the KNOWAutism Foundation to contact individuals and entities listed on this application for verification and to collect additional information, if needed. I understand a maximum of one application per scholarship applicant may be submitted every twelve (12) months from the date of the last application. I understand I may withdraw my application, at any time, in writing to info@know-autism.org. I understand all scholarships will be paid directly to the service or program provider.
Signature
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Full Name
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Today's Date
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Month
-
Day
Year
2024 Tax Return for Parent/Guardian #1 (social security numbers may be redacted):
*
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2024 Tax Return for Parent/Guardian #2 (social security numbers may be redacted):
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Invoice for Program/Services being requested:
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Medical Insurance Card for child (front):
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Medical Insurance Card for child (back):
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Medcaid card front:
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Certified Divorce Decree/Custodial Agreement, if applicable:
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Other (anything additional you'd like us to know):
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