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

Choose between two sections: 
Diagnostic Services (seeking diagnosis) or Intervention Services (have confirmed diagnosis).

Referral for DIAGNOSTIC SERVICES for Adult Client

An adult who is seeking diagnostic testing from the Greensboro TEACCH® Center must complete the History Form and obtain a Professional Referral Form.  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 Adult Client completed by the Adult Client
  2. 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.
  3. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  4. 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.

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

Please send completed paperwork 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


Referral for INTERVENTION SERVICES for Adult Client

An adult who is seeking intervention services from the Greensboro TEACCH Center and already has a documented diagnosis of Autism Spectrum Disorder must complete only complete the History Form.  Please click on the link below to download the form. Please note these forms can be completed and saved on the computer.

  1. History Form for Adult Client completed by the Adult Client
  2. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder
  3. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  4. 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.

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

Please send completed paperwork 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