Refer a student to Clarity Pediatrics
For learning specialists and school professionals. Tell us about the student, what you're seeing at school, and how we can best work with you and the family. It takes about five minutes.Clarity Pediatrics currently serves families with children ages 5–17 in California and Texas.
Referrer Information
Tell us who's making this referral.
Name
*
First Name
Last Name
Your title / role
*
Please Select
Learning Specialist
School Counselor
School Psychologist
Classroom Teacher
Special Education Teacher
School Nurse
School Administrator
Speech Language Pathologist
Occupational Therapist
Other
School name
*
School district (optional)
Work email
*
example@example.com
Work Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Parent/Caregiver Information
Who should Clarity contact about this student?
Parent/Caregiver's Name
*
First Name
Last Name
Parent/Caregiver's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Caregiver's Email (optional, but preferred)
example@example.com
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Child / Student Information
Tell us about the student you're referring.
Child's Name
*
First Name
Last Name
Child's date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Child's State of Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
US Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Child's Primary Language
*
Please Select
English
Spanish
Other
Is this student insured through Medicaid (e.g., Medi-Cal managed care plan or Medi-Cal)? (optional)
Yes
No
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Reason for referral
Tell us the reason for this referral.
I'm referring this student to Clarity Pediatrics for:
*
ADHD concerns
Anxiety concerns
Other learning or behavioral concerns
Please describe the reason for referral
*
Have any formal assessments been completed?
*
Yes
No
Please list the assessments that have been completed
For example: psychoeducational evaluation, IEP or 504 evaluation, speech-language or occupational therapy assessment — and when they were completed, if known.
Is there an existing diagnosis?
*
Yes
No
Please list the existing diagnosis or diagnoses
And who made the diagnosis, if known.
Do you suspect any other learning differences?
*
Yes
No
Please describe the learning differences you suspect
For example: dyslexia, processing differences, language disorder, autism spectrum traits.
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Observations & supports
What you — and the family — are seeing, and what's already been tried.
What behaviors do you observe at school?
*
What behaviors are seen at home? (optional)
As reported by parents/caregivers, if known.
Accommodations already used — select all that apply (optional)
Timers
Differentiated or flexible seating
Fidget tools
Planners or organizers
Checklists
Movement breaks
Preferential seating near instruction
Small-group or 1:1 support
Extended time
Other
Please describe the accommodations that have been used, and whether they've been effective
Optional
Have the student's parents/caregivers been informed of this referral?
*
Yes
No
Please describe
For example: who you spoke with, when, and how they responded.
Do you know of any family history of ADHD, anxiety, or learning differences? In a parent, sibling, or other close relative.
*
Yes
No
Not sure
Please share any details you're comfortable sharing (optional)
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Liaison & documents
How we should work with you and the family.
Would you be able — or prefer — to act as a liaison between Clarity and the family, if needed?
Yes, I can act as a liaison
Yes, I'd prefer to act as a liaison
Only if it's really needed
No — please work with the family directly
Why might that be the best path? (optional)
For example: the family does not speak English, feels intimidated by this process, or has limited availability.
Supporting documents (optional)
Browse Files
Drag and drop files here
Choose a file
Add report cards, assessment reports, or an IEP / 504 plan
Cancel
of
Anything else you'd like the Clarity team to know about this student? (optional)
Submit
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