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 Adult Client

An adult who is seeking diagnostic testing from the Wilmington TEACCH® Center must complete the History Form and obtain a Professional Referral Form. Click on the links below to download the forms. Please note these forms can be completed and saved on the computer.

  1. History Form for Adult Client completed by the Adult Client
  2. Adult Professional Referral completed by a qualified professional who has 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 and a copy of client’s insurance card to:
Wilmington TEACCH Center – Attention Kay Sanderlin
503 Covil Avenue, Suite 100, Wilmington, NC 28403 or Fax: 910-251-5809
Questions? Call 828-251-6319

Referral for Intervention Services for Adult Client

An adult who is seeking intervention services from the Wilmington TEACCH Center and already has a documented diagnosis of Autism Spectrum Disorder must complete only complete the History Form. Please click on the link below to download the form. Please note these forms can be completed and saved on the computer.

  1. History Form for Adult Client completed by the Adult Client
  2. Diagnostic report confirming the diagnosis of Autism Spectrum Disorder
  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 and a copy of client’s insurance card to:
Wilmington TEACCH Center – Attention Kay Sanderlin
503 Covil Avenue, Suite 100, Wilmington, NC 28403 or Fax: 910-251-5809
Questions? Call 828-251-6319