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“Greensboro

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 through age 17

Families who are seeking diagnostic testing from the Greenboro TEACCH® Center for a child up through age 17, must complete the History Form and obtain a Professional Referral Form. Click on the links below to download the forms. Please note these forms can be completed and saved on the computer. Once the form is completed, save the form to your computer again and then print/fax/mail forms to your TEACCH Center.

  1. History Form for ALL Clients to be completed by the parents/guardians of the child. Versión en español
  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. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form must also be submitted.
  4. Research Forms – Please review these forms and brochure – English and Spanish 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.
  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 – English | Español

Please send completed paperwork and a copy of the client’s insurance card to:
Greensboro TEACCH Center Attention: Bailey Coe
925 Revolution Mill Drive, Suite 7, Greensboro, NC 27405 or Fax: 919-445-2354
Questions? Call 919-966-1046

Referral for Intervention Services for Children and Adolescents through age 17

Families who are seeking intervention services from the Greensboro TEACCH Center for a child or adolescent who already has a documented diagnosis of Autism Spectrum Disorder must only complete a History Form. Click on the link below to download the form. Please note these forms can be completed and saved on the computer. Once the form is completed, save the form to your computer again and then print/fax/mail forms to your TEACCH Center.

  1. History Form for ALL Clients to be completed by the parents/guardians of the child. Versión en español
  2. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder must be submitted.
  3. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form must also be submitted.
  4. Research Forms – Please review these forms and brochure – English and Spanish 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.
  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 – English | Español

Please send completed paperwork and a copy of the client’s insurance card to:
Greensboro TEACCH Center Attention: Bailey Coe
925 Revolution Mill Drive, Suite 7, Greensboro, NC 27405 or Fax: 919-445-2354
Questions? Call 919-966-1046