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 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. History Form for Children and Adolescents completed by the parents/guardians of the child. Spanish version
  2. 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.
  3. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  4. 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.
  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

Please send completed paperwork, a copy of client’s insurance card to:
Raleigh TEACCH Center
4301 Lake Boone Trail, Suite 200, Raleigh, NC 27607  Fax 919-445-0700
Questions? Call 919-445-9999

Referral Forms for Intervention Services for Children and Adolescents

Families who are seeking services from the Raleigh TEACCH Center for an adult who already has a documented diagnosis of Autism Spectrum Disorder must only complete the History Form. Click on the links below to download the forms. Please download and save the fillable form to your computer firstbefore filling in information. Once form is completed, save the form to your computer again and then print/fax/scan/email forms to your TEACCH Center.

  1. History Form for Children and Adolescents completed by the parents/guardians of the child. Spanish version
  2. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  3. 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.
  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

Please send completed paperwork, a copy of client’s insurance card to:
Raleigh TEACCH Center
4301 Lake Boone Trail, Suite 200, Raleigh, NC 27607  Fax 919-445-0700
Questions? Call 919-445-9999