Referral

To make a referral for services at the Greensboro TEACCH® Center, please complete the appropriate forms.  Once the completed forms and requested reports are received by the Greensboro TEACCH Center, you will be contacted to do a screening and speak with a staff person about our services.  If additional forms are needed, you will be directed to the appropriate ones.

- For clients seeking a diagnostic evaluation, you will be scheduled for an initial family consultation where you will come into the Center 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 asked to send us the report to document this diagnosis  and contacted by phone to talk with an Autism Specialist 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, please contact 336-334-5773 or email Vicki Matier at vmatier@med.unc.edu

    To read Notice of Privacy Practice - English | Spanish 
    General Consent for Treatment - English | Spanish
    UNC Patient Rights - English | Spanish
    Release of Medical Information and Confidentiality Authorization Form - English |  Spanish

     

    REFERRAL FORMS for Children and Adolescents (through age 17)

    REFERRAL FORMS for Adult Client (age 18 and older who is NOT his/her OWN GUARDIAN)

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

    Please send all of the completed forms and a copy of client's insurance card to the following address or fax to the number below:

    Greensboro TEACCH Center 
    Attention: Vicki Matier
    925 Revolution Mill Drive, Suite 7
    Greensboro, NC 27405
    Fax: 336-334-5811