Referral

To make a referral for diagnostic evaluation services at the Fayetteville TEACCH® Center, please complete the appropriate forms. Once the completed forms and requested reports are received by the Fayetteville TEACCH Center, you will be contacted to schedule an appointment.

  • These questionnaires provide information necessary for TEACCH personnel to determine whether or not TEACCH offers diagnostic 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.
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

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

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 above. 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