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 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.
  4. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  5. Research Forms – Please review these forms and brochurebefore 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 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:
Greenville TEACCH Center
South Hall Professional Center, 108-D West Fire Tower Road
Winterville, NC 28590  or Fax: 252-830-3322
Questions? Call 252-830-3300 ext. 221

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. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder must be submitted.
  4. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  5. 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. 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 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:
Greenville TEACCH Center
South Hall Professional Center, 108-D West Fire Tower Road
Winterville, NC 28590  or Fax: 252-830-3322
Questions? Call 252-830-3300 ext. 221