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

Referral for DIAGNOSTIC SERVICES for Adult Client (who is his/her OWN guardian)

An adult who is seeking diagnostic testing from the Fayetteville TEACCH® Center must complete the History Form and obtain a Professional Referral Form.  Click on the links below to download the forms.  Please note, forms can be completed and saved on the computer.

  1. History Form for Adult Client completed by the Adult Client
  2. Diagnostic Questionnaire
  3. 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.
  4. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  5. 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
  6. 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

Please note: This is a satellite clinic. Because we are not in Fayetteville every day, please do not drop off any paperwork at our Fayetteville location. All paperwork must be mailed to the address listed below. This is so that we can provide our families with the utmost privacy. Thank you for your understanding. If you have any questions, please contact 

Please send all of the completed forms as well as a copy of driver’s license or photo ID and copies (front and back) of all insurance cards, Medicaid, and/or Tricare cards, and military ID's to the following address or fax to the number below. 

Fayetteville TEACCH Center
University of North Carolina
CB#7180 Chapel Hill, NC 27599-7180

FAX:  919-966-4127