Referral Forms for Diagnostic Services for Children and Adolescents

Families who are seeking diagnostic testing, for their child up through age 17, from the Raleigh TEACCH® Center must complete the History Form and obtain a Professional Referral Form. Click on the links below to download the forms. Please note, forms can be completed and saved on the computer.

  1. 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.
  2. History Form for Children and Adolescents completed by the parents/guardians of the child. Spanish version
  3. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted. Examples (if applicable, must include copies of): IEPs; school testing report(s); CDSA evaluation(s); notes from speech, occupational, and/or play therapy; notes from other mental health providers, etc. Please only include the most recent copy of IEP, therapy evals, etc.)
  4. 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, a copy of client’s insurance card, and copy of ID to:
Raleigh TEACCH Center
4301 Lake Boone Trail, Suite 200, Raleigh, NC 27607  Fax 919-445-0700
Questions? Call 919-445-9993