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 Children and Adolescents

  1. History Form for Children and Adolescents completed by the parents/guardians of the child. Spanish version
  2. Parent/Guardian Diagnostic Questionnaire completed by the parents/guardians of the child
  3. Child/Adolescent Professional Referral completed by the child’s primary care provider if Medicaid or Tricare Prime recipient.
  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) brochure (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. 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. Spanish version

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: 252-830-3322
or email kathleen_holler@med.unc.edu 
Questions? Call 252-830-3300 ext. 222

Referral for Intervention Services for Children and Adolescents

Families who are seeking intervention services from the Greenville TEACCH® Center for a child or adolescent who already has a documented diagnosis of Autism Spectrum Disorder must complete a History Form and Diagnostic Questionnaire. Click on the link 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/Guardian Diagnostic Questionnaire completed by the parents/guardians of the child
  3. Child/Adolescent Professional Referral completed by the child’s primary care provider if Medicaid or Tricare Prime recipient.
  4. Documentation of diagnosis or educational classification of Autism Spectrum Disorder must be submitted.
  5. Any other previous diagnostic and/or cognitive evaluation reports as indicated in the History form.
  6. Research Forms – Please review these forms and brochure (English) brochure (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. You are NOT required to participate in research to receive TEACCH services.
  7. 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. Spanish version

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: 252-830-3322
or email kathleen_holler@med.unc.edu 
Questions? Call 252-830-3300 ext. 222