Referral Forms for Children and Adolescents (through age 17) at Raleigh Center
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.
- 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.
- History Form for ALL Clients to be completed by the parents/guardians of the child. Spanish version
- 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.)
- 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
- UNC General Consent for Treatment – English | Spanish
- 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.
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