Referral Forms for Children and Adolescents (through age 17) Chapel Hill

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

Referral for DIAGNOSTIC SERVICES for Children and Adolescents

Families who are seeking diagnostic testing from the Chapel Hill TEACCH Center for a child up through age 17, must complete the History Form and obtain a Professional Referral Form.  Click on the links below to download the forms.  Please note these forms can be completed and saved on the computer.

  1. History Form for Children and Adolescents completed by the parents/guardians of the child
  2. Child/Adolescent 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.

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 Children and Adolescents

Families who are seeking intervention services from the Chapel Hill TEACCH Center for a child or adolescent who already has a documented diagnosis of Autism Spectrum Disorder must only complete a History Form.  Click on the link below to download the form. Please note these forms can be completed and saved on the computer.

  1. History Form for Children and Adolescents completed by the parents/guardians of the child
  2. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder must be submitted.
  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.

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