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

Choose between two sections:
Diagnostic Services (seeking diagnosis) or Intervention Services (have confirmed diagnosis).

Referral for DIAGNOSTIC SERVICES for Adult Client

An adult who is seeking diagnostic testing from the Chapel Hill TEACCH Center must complete the History Form and obtain a Professional Referral Form.  Click on the links below to download the forms.  Please download and save the fillable form to your computer first before filling in information. Once form is completed, save the form to your computer again and then print/fax/scan/email forms to your TEACCH Center.

  1. History Form for Adult Client completed by the Adult Client
  2. Adult Professional Referral completed by a qualified professional:  Physician, Nurse, Psychiatrist, Psychologist, Social Worker, Occupational Therapist, Teacher or other school personnel, Case Manager, Counselor, Speech Therapist or Mental Health Worker.  This professional must have knowledge of the client and an understanding of what ASD symptoms are present.
  3. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  4. Research Forms - Please review these forms and brochure before your clinic visit so that you can be informed about our research at TEACCH. You may sign and return them before or during your visit. You are NOT required to participate in research to receive TEACCH services.
  5. Release of Information Form - If you wish to be able to communicate by email with TEACCH Staff at any point, you must complete and submit this form. spanish version

If you have any questions regarding the requested paperwork or the referral process, please call Catherine Jones at (919)-966-5156 or email catherine_jones@med.unc.edu

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

Chapel Hill TEACCH Center University of North Carolina
Attention: Catherine Jones
CB#6305 Chapel Hill, NC 27599

or Fax: 919-966-4003


Referral for INTERVENTION SERVICES for Adult Client

An adult who is seeking intervention services from the Chapel Hill TEACCH Center and already has a documented diagnosis of Autism Spectrum Disorder must complete only complete the History Form.  Click on the links below to download the forms.  Please download and save the fillable form to your computer first before filling in information. Once form is completed, save the form to your computer again and then print/fax/scan/email forms to your TEACCH Center.

  1. History Form for Adult Client completed by the Adult Client
  2. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder
  3. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  4. Research Forms - Please review these forms and brochure before your clinic visit so that you can be informed about our research at TEACCH. You may sign and return them before or during your visit. You are NOT required to participate in research to receive TEACCH services
  5. Release of Information Form - If you wish to be able to communicate by email with TEACCH Staff at any point, you must complete and submit this form. spanish version

If you have any questions regarding the requested paperwork or the referral process, please call Catherine Jones at (919)-966-5156 or email catherine_jones@med.unc.edu.

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

Chapel Hill TEACCH Center University of North Carolina
Attention: Catherine Jones
CB#6305 Chapel Hill, NC 27599

or Fax: 919-966-4003