Referral

To make a referral for services at Greenville TEACCH® Center, please complete the appropriate forms. Once the completed forms and requested reports are received by the Greenville TEACCH Center, you will be contacted to schedule an appointment. Please refer to packet checklist before mailing packet to ensure you have completed all necessary documents.

- For clients seeking a diagnostic evaluation, you will be scheduled for a screening appointment 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 scheduled to meet with an Autism Specialist to learn 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 the referral process, please call Sharonda Smith at 252-830-3300 ext. 221 or email sharonda_sutton-smith@med.unc.edu

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

 

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:
Please refer to packet checklist before mailing packet to ensure you have completed all necessary documents. 

Greenville TEACCH Center
South Professional Center 108-D Fire Tower Road
Winterville, NC 28590

Fax 252-830-3322