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Services Across the Lifespan for Individuals with Autism Spectrum Disorder
“Greenville

Referral Forms for Adult Client (age 18)

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 Services for Adult Client

An adult who is seeking diagnostic testing from the Greenville TEACCH® Center 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 Adult Client. Versión en español
  2. Adult Professional Referral completed by primary care provider if Medicaid or Tricare Prime recipient.
  3. Any other previous diagnostic and/or cognitive evaluation reports as indicated in the History form.
  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 or if you would like for us to communicate with family members or others who support you, 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:
Greenville TEACCH Center
South Hall Professional Center, 108-D West Fire Tower Road
Winterville, NC 28590  or Fax: 919-445-2356
Questions? Call 919-966-0212 

Referral for Intervention Services for Adult Client

An adult who is seeking intervention services from the Greenville TEACCH Center and already has a documented diagnosis of Autism Spectrum Disorder must complete the History Form. Please 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 Adult Client. Versión en español
  2. Adult Professional Referral completed by primary care provider if Medicaid or Tricare Prime recipient.
  3. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder
  4. Any other previous diagnostic and/or cognitive evaluation reports as indicated in the History form.
  5. 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.
  6. Release of Information Form – If you wish to be able to communicate by email with TEACCH Staff or if you would like for us to communicate with family members or others who support you, at any point, you must complete and submit this form. Versión en español
  7. UNC General Consent for Treatment – English | Español

Please send completed paperwork and a copy of the client’s insurance card to:
Greenville TEACCH Center
South Hall Professional Center, 108-D West Fire Tower Road
Winterville, NC 28590  or Fax: 919-445-2356
Questions? Call 919-966-0212