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 Children and Adolescents

Families who are seeking diagnostic testing from the Charlotte TEACCH Center for a child up through age 17, must complete the forms listed below. 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. Spanish version
  2. 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.
  3. Parent Diagnostic Questionnaire (each parent needs to complete a separate form)
  4. Behavior Symptom Checklist
  5. School Information Questionnaire
  6. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  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 must complete and sign the forms BEFORE your visit can be scheduled. You are NOT required to participate in research to receive TEACCH services.
  8. 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

Please send completed paperwork and a copy of client’s insurance card to:
Charlotte TEACCH Center
5701 Executive Center Drive, Suite 108, Charlotte, NC 28212 or Fax: 704-563-4112
Questions? Call 704-563-4103

Referral for Intervention Services for Children and Adolescents

Families who are seeking intervention services from the Charlotte TEACCH Center for a child or adolescent who already has a documented diagnosis of Autism Spectrum Disorder must only complete the forms listed below. 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. Spanish version
  2. Parent Diagnostic Questionnaire (each parent needs to complete a separate form)
  3. Behavior Symptom Checklist
  4. School Information Questionnaire
  5. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder must be submitted.
  6. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  7. Research Forms – Please review these forms and brochurebefore your clinic visit so that you can be informed about our research at TEACCH. You must complete and sign the forms BEFORE your visit can be scheduled. You are NOT required to participate in research to receive TEACCH services.
  8. 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

Please send completed paperwork and a copy of client’s insurance card to:
Charlotte TEACCH Center
5701 Executive Center Drive, Suite 108, Charlotte, NC 28212 or Fax: 704-563-4112
Questions? Call 704-563-4103