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Referral Forms for Diagnostic Services for Adult Client

An adult who is seeking diagnostic testing from the Asheville 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/fax/scan/email forms to the Asheville TEACCH Center. We are unable to schedule your family without the first three items.

  1. 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.
  2. History Form for ALL Clients completed by the Adult Client
  3. Copy of client’s insurance card and photo ID.
    Please also submit the following items:
  4. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form must also be submitted. Examples (if applicable, must include copies of): 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.)
  5. Release of Information Form If you wish to be able to communicate by email with TEACCH Staff at any point, you must complete and submit this form. Spanish version
  6. UNC General Consent for Treatment – Spanish version
  7. 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 servicesSpanish version  |  brochure (Spanish)

Referral Forms for Intervention Services for Adult Client

An adult who is seeking intervention services from the Asheville TEACCH Center and already has a documented diagnosis of 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 again and then print/fax/scan/email forms to the Asheville TEACCH Center. We are unable to schedule your family without the first three items.

  1. A diagnostic report confirming the diagnosis of Autism Spectrum Disorder must be submitted
  2. History Form for ALL Clients  to be completed by the Adult Client
  3. Copy of client’s insurance card and photo ID.
    Please also submit the following items:
  4. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form must also be submitted. Examples (if applicable, must include copies of): 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.)
  5. Release of Information FormIf you wish to be able to communicate by email with TEACCH Staff at any point, you must complete and submit this form. Spanish version
  6. UNC General Consent for Treatment – Spanish version
  7. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form must also be submitted.
  8. 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 servicesSpanish version  |  brochure (Spanish)

Please send completed paperwork and a copy of the client’s insurance card to:
Asheville TEACCH Center
100 Technology Drive, Suite A, Asheville, NC 28803 or Fax: 919-445-2352
Questions? Call 919-445-7020  or TEACCH_Asheville@med.unc.edu