The type of assistance available varies based on certain criteria including but not limited to your household income and your insurance status. To receive assistance from this Patient Assistance & Support Program, you must complete and submit this application form in its entirety and meet programme eligibility requirements.Once you have submitted your application, a representative from Unlimigo® will reach out to you with next steps.

If you have any questions while submitting the application, please call the programme at +1 (901) 240 5040. We are available to answer your calls Monday through Friday, from 9AM to 9PM Eastern Time.

As an alternative to the application below, you can complete an editable PDF here and send it in via the instructions on the form.

Please ensure you have a valid prescription for Unlimitics before completing this application.

Patient Assistance Program Application

Please fill out all fields

Patient Personal Information
Parent/Legal Guardian Financial Information
Please Enter The Total Combined Income For You, Your Spouse, And Your Dependents (Annually):
Insurance information
For each policy you have that provides coverage for the patient, please attach a copy of both sides
of your insurance card and fill in the following:
Primary Insurance
Upload Front Here
Upload Back Here
Secondary Insurance (If Applicable)
Upload Front Here
Upload Back Here
*File types accepted: .png, .jpeg, .pdf. Max file size 5MB
Patient Authorization

I certify that the information I have provided in this form is accurate and complete. I authorize Unlimitics to use my information to determine eligibility for financial assistance or as otherwise permitted by law. Submission of this form does not constitute approval or guarantee eligibly to receive discounted services. The guidelines for providing hardship assistance may change or the program may be discontinued without notice. I have read and agree to the Patient Authorization above

By submitting this form, you consent to Unlimitics processing your and/or your child’s data or personal information in accordance with Unlimitics’ Privacy Policy, and you agree to the Terms of Use of Unlimitics’ sites.


By submitting this form, you consent to Unlimitics processing your and/or your child’s data or personal information in accordance with Unlimitics Privacy Policy and Unlimitics’s HIPAA Notice, and you agree to the Terms of Use of Akili’s sites.

Unlimitics:

Instructions For Use

Indications:
Unlimitics is a generative AI school simulation game indicated to optimise executive function for school-aged children who might experience problems associated with execution dysfunction. Unlimitics should be considered for use as part of a therapeutic programme that may include clinician-directed therapy, medication, and/or educational programs, which further addresssymptoms of the disorder.

Safety:
If your child / student experiences frustration, emotional reaction, dizziness, nausea, headache, eye-strain, or joint pain while playing Unlimitics, pause the treatment. If the problem persists contact your child’s healthcare provider. If your child experiences a seizure stop the treatment and contact your child’s healthcare provider.

Unlimitics may not be appropriate for patients with photo-sensitive epilepsy, color blindness, or physical limitationsthat restrict use of a mobile device; parents should consult with their child’s healthcare provider.

Please follow all of your mobile device manufacturer’s instructions for the safe operation of your mobile device.For example, this may include appropriate volume settings, proper battery charging, not operating the device if damaged, and proper device disposal. Contact your mobile device manufacturer for any questions or concerns that pertain to your device.