To make a referral for services at the Charlotte TEACCH Center, please complete the appropriate forms.  Once the completed forms and requested reports are received by the Charlotte 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, contact 704-563-4103 or email

    To read Notice of Privacy PracticeEnglish | Spanish 
    General Consent for TreatmentEnglish | Spanish
    UNC Patient RightsEnglish | 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 to the following address or fax to the number below:

    Charlotte TEACCH Center 
    5701 Executive Center Drive, Suite 108
    Charlotte, NC 28212
    Fax: 704-563-4112