Referral Forms for Children and Adolescents (through age 17)

Referral Forms for DIAGNOSTIC SERVICES for Children and Adolescents

Families who are seeking diagnostic testing, for their child up through age 17, from the Fayetteville 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
  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. Parent Diagnostic Questionnaire (each parent needs to complete a separate form)
  4. Any other previous diagnostic and/or cognitive evaluation reports as indicated on the History form, must also be submitted.
  5. 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.
  6. 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 note: This is a satellite clinic. Because we are not in Fayetteville every day, please do not drop off any paperwork at our Fayetteville location. All paperwork must be mailed to the address listed below. This is so that we can provide our families with the utmost privacy. Thank you for your understanding. If you have any questions, please contact  

Please send all of the completed forms as well as a copy of driver’s license or photo ID and copies (front and back) of all insurance cards, Medicaid, and/or Tricare cards, and military ID's to the following address or fax to the number below. 

Fayetteville TEACCH Center
University of North Carolina
CB#7180 Chapel Hill, NC 27599-7180

FAX:  919-966-4127