Referral Information for Diagnostic Evaluation
DIAGNOSTIC SERVICES:
Individuals and families who are seeking diagnostic testing for themselves or their child from a TEACCH® Center must complete the documents below. Click on the links below to download the forms. Please download and save the fillable form to your computer first before filling in the information. Once the form is completed, save the form to your computer again and then print and fax/mail/drop off forms to your local TEACCH Center.
Referral Forms for Diagnostic Services
We are unable to schedule your family without the first four items:
1) Professional Referral FormProfessional Referral Form to be 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.
History Form to be completed by the individual or parents/guardians of the child.
Please also submit the following items:
5. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form should also be submitted. Examples include: IEPs; school testing report(s); CDSA evaluation(s); notes from speech, occupational, and/or play therapy; notes from other mental health providers, etc. Please only include the most recent copy of IEP, therapy evals, etc.
Please review the research documents below before your appointment:
6. Research Forms – Please review the brochure and forms below 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.