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Services Across the Lifespan for Individuals with Autism Spectrum Disorder

Referral Information for Intervention Therapy Services

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INTERVENTION/THERAPY SERVICES

Individuals and families seeking intervention/therapy services from a TEACCH® Center for themselves or their child who already have a documented diagnosis of an Autism Spectrum Disorder 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 and then print and fax/mail/drop off forms to your local TEACCH Center. 

 

Referral Forms for Intervention/Therapy Services

We are unable to schedule your family without the first four items:

2) History Form - English
2) History Form - Español

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 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.

Research Brochure - English Research Brochure - Español
Research Form - Child/Adolescent - English Research Form - Child/Adolescent - Español
Research Form - Adult - English Research Form - Adult - Español
Research Form - Adult w/Legal Guardian - English Research Form - Adult w/Legal Guardian - Español

 

If you have any questions about the referral process, please contact your local TEACCH Center