Referral Forms for Children and Adolescents (through age 17) Greenville

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

Referral for DIAGNOSTIC SERVICES for Children and Adolescents

Families who are seeking diagnostic testing from the Greenville TEACCH® Center for a child up through age 17, must complete the History Form, Diagnostic Questionnaire 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 Children and Adolescents completed by the parents/guardians of the child
  2. Parent/Guardian Diagnostic Questionnaire completed by the parents/guardians of the child
  3. Child/Adolescent 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.

If you have any questions regarding the requested paperwork or the referral process, please call Sharonda Smith at (252)-830-3300 ext. 221 or email sharonda_sutton-smith@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:

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

or Fax: 252-830-3322


Referral for INTERVENTION SERVICES for Children and Adolescents

Families who are seeking intervention services from the Greenville TEACCH Center for a child or adolescent who already has a documented diagnosis of Autism Spectrum Disorder must complete a History Form and Diagnostic Questionnaire.  Click on the link below to download the forms. Please note these forms can be completed and saved on the computer.

  1. History Form for Children and Adolescents completed by the parents/guardians of the child
  2. Parent/Guardian Diagnostic Questionnaire completed by the parents/guardians of the child
  3. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder must be submitted.
  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.

If you have any questions regarding the requested paperwork or the referral process, please call Sharonda Smith at (252)-830-3300 ext. 221 or email sharonda_sutton-smith@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:

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

or Fax: 252-830-3322