Refer a Patient for Therapy or Psychological Evaluation

Clear Foundations is Here to Help

Clear Foundations provides therapy, comprehensive psychological and psychoeducational evaluations for children, adolescents, and adults. Our evaluations help clarify diagnoses and provide practical recommendations for treatment, school, and workplace functioning.

Providers can submit a referral in less than one minute using the form below.

Questions? Contact our office at 704-378-8595

Reason for referral: Check all that apply(Required)

Therapy

Testing

ADHD Evaluation

Autism Spectrum Evaluation

Learning and Academic Concerns

School Admission Testing

High Stakes Testing Accommodations (MCAT, GRE, ACT etc.)

Diagnostic Clarification/Other Emotional and Behavioral Concerns

Evaluation to Guide Treatment Planning

Payment Information

We accept private credit cards, debit cards, HSA/FSA cards, and Care Credit for payment. We also accept most Aetna, BCBS, and Medcost insurance plans, including NC State Health Plan. We are out-of-network with BCBS EPO plans (Blue Home, High Performance Network, etc.). We also accept ESA+ Scholarship Funds. We do not accept Medicaid or Medicare.

Referring Provider Information

Provider Name(Required)
First Last

Practice/Organization(Required)

Phone Number(Required)

Email Address(Required)

Would you like to receive a copy of the report?(Required)

Patient Information

Patient Name(Required)
First Last

Date of Birth(Required)

Parent / Guardian Name (if applicable)(Required)