To make a referral for services at the Chapel Hill TEACCH Center, please complete the appropriate forms.  Once the completed forms and requested reports are received by the Chapel Hill TEACCH Center, you will be contacted to schedule an appointment.

- For clients seeking a diagnostic evaluation, you will be scheduled for a screening appointment to meet with an Autism Specialist to determine if testing for Autism Spectrum Disorder is appropriate.

- For clients who have a confirmed diagnosis of ASD, you will be scheduled to meet with an Autism Specialist to learn about available TEACCH services.

  • These questionnaires provide information necessary for TEACCH personnel to determine whether or not TEACCH offers appropriate services for you or your family member.
  • By voluntarily providing this information you facilitate the screening process.
  • Submitting the questionnaires does not create a provider relationship with TEACCH. Any clinical/provider relationship will be determined based on the screening results.
  • The most secure method for sending this information is via US Postal mail, if you choose to submit any information via email, understand that TEACCH cannot guarantee the security of the transmission.

If you have any questions regarding the forms or referral process, please contact 919-966-5156 or email Catherine Jones at

    To read Notice of Privacy Practice - English | Spanish 
    General Consent for Treatment - English | Spanish
    UNC Patient Rights - English | Spanish
    Release of Medical Information and Confidentiality Authorization Form - English |  Spanish


    REFERRAL PROCESS and FORMS for Children and Adolescents (through age 17)

    REFERRAL PROCESS and FORMS for Adult Client (age 18 and older who is NOT his/her OWN GUARDIAN)

    REFERRAL PROCESS and FORMS for Adult Client (age 18 and older who is his/her OWN GUARDIAN)

    Please send all of the completed forms and a copy of client's insurance card to the following address or fax to the number below:

    Chapel Hill TEACCH Center
    Attention: Catherine Jones
    CB#6305 UNC-Chapel Hill
    Chapel Hill, NC 27599
    Fax: 919-966-4003