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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 documents below. Click on the links below to download the forms. Please download and save the fillable form to your computer first before filling in the information. Once the form is completed, save the form to your computer again and then print/fax/scan/email forms to your TEACCH Center. We are unable to schedule your family without the first three items.

  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 ALL Clients to be completed by the parents/guardians of the child. Spanish version
  3. Copy of client’s insurance card and parent/guardian photo ID.
    Please also submit the following items:
  4. 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.)
  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 Spanish version
  6. UNC General Consent for Treatment  | Spanish version
  7. 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.  Spanish version  |  brochure (Spanish)

Referral Forms for Intervention Services for Children and Adolescents

Families who are seeking intervention services from the Raleigh TEACCH® Center for a child or adolescent who already has a documented diagnosis of an Autism Spectrum Disorder must complete the documents below. Click on the links below to download the forms. Please download and save the fillable form to your computer first before filling in the information. Once the form is completed, save the form to your computer again and then print/fax/scan/email forms to your TEACCH Center. We are unable to schedule your family without the first three items.

  1. Diagnostic report confirming the diagnosis of an Autism Spectrum Disorder must be submitted.
  2. History Form for ALL Clients to be completed by the parents/guardians of the child. Spanish version
  3. Copy of client’s insurance card and parent/guardian photo ID.
    Please also submit the following items:
  4. 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.)
  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 Spanish version
  6. UNC General Consent for Treatment  | Spanish version
  7. 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.  Spanish version  |  brochure (Spanish)

Please send completed paperwork, a copy of the client’s insurance card, and a copy of ID to:
Raleigh TEACCH Center
4301 Lake Boone Trail, Suite 200, Raleigh, NC 27607  Fax 919-445-5799
Questions? Call 919-445-5793