Skip to main content
“Chapel

Choose appropriate criteria for Referral Forms:

  • For clients seeking a diagnostic evaluation:  Fill out the intake forms under the Diagnostic Testing section
  • For clients who have a confirmed diagnosis of ASD and seeking Intervention: Fill out the intake forms under the Intervention Services section

Referral for Diagnostic Testing for Adult Client

An adult who is seeking diagnostic testing from the Chapel Hill 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 your 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 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 Form – If you wish to be able to communicate by email with TEACCH Staff at any point, you must complete and submit this form. Versión en español
  6. UNC General Consent for Treatment –| Versión en español
  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. Versión en español  |  Folleto (español).  You are NOT required to participate in research to receive TEACCH services.

Please send completed paperwork and a copy of the client’s insurance card to:
Chapel Hill TEACCH Center
100 Renee Lynne Court, Carrboro, NC 27510 or Fax: 919-966-4003

Questions? Email TEACCH_ChapelHill@med.unc.edu or Call (919)-966-5156

Referral for Intervention Services for Adult Client

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

  1. A diagnostic report confirming the diagnosis of an 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 Form – If you wish to be able to communicate by email with TEACCH Staff at any point, you must complete and submit this form. Versión en español
  6. UNC General Consent for Treatment –| Español
  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.  Versión en español  |  Folleto (español).  You are NOT required to participate in research to receive TEACCH services.

Please send completed paperwork and a copy of the client’s insurance card to:
Chapel Hill TEACCH Center
100 Renee Lynne Court, Carrboro, NC 27510 or Fax: 919-966-4003

QQuestions? Email TEACCH_ChapelHill@med.unc.edu or Call (919)-966-5156