Referral Forms for Children and Adolescents (through age 17) Charlotte

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 Charlotte TEACCH Center for a child up through age 17, must complete the forms listed below.  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. Parent Diagnostic Questionnaire (each parent needs to complete a separate form)
  4. Behavior Symptom Checklist
  5. School Information Questionnaire
  6. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  7. Research Forms - Please review these forms and brochure before your clinic visit so that you can be informed about our research at TEACCH. You must complete and sign the forms BEFORE your visit can be scheduled. 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 (704) 563-4103 or email TEACCH_Charlotte@med.unc.edu

Please send completed paperwork to the following address or fax to the number below:

Charlotte TEACCH Center 
5701 Executive Center Drive, Suite 108
Charlotte, NC 28212

or Fax: 704-563-4112


Referral for INTERVENTION SERVICES for Children and Adolescents

Families who are seeking intervention services from the Charlotte TEACCH Center for a child or adolescent who already has a documented diagnosis of Autism Spectrum Disorder must only complete the forms listed below.  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. Parent Diagnostic Questionnaire (each parent needs to complete a separate form)
  3. Behavior Symptom Checklist
  4. School Information Questionnaire
  5. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder must be submitted.
  6. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  7. Research Forms - Please review these forms and brochure before your clinic visit so that you can be informed about our research at TEACCH. You must complete and sign the forms BEFORE your visit can be scheduled. 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 (704) 563-4103 or email TEACCH_Charlotte@med.unc.edu

Please send completed paperwork to the following address or fax to the number below:

Charlotte TEACCH Center 
5701 Executive Center Drive, Suite 108
Charlotte, NC 28212

or Fax: 704-563-4112