To make a referral for services at the Raleigh TEACCH Center, please complete the appropriate forms.  Once the completed forms and requested reports are received by the Raleigh TEACCH Center, you will be contacted to schedule a consultation.

  • These questionnaires provide information necessary for TEACCH personnel to determine whether or not TEACCH offers appropriate services for you or your family member.
  • By voluntarily providing this information you facilitate the screening process.
  • Submitting the questionnaires does not create a provider relationship with TEACCH. Any clinical/provider relationship will be determined based on the screening results.

The most secure method for sending this information is via US Postal mail, if you choose to submit any information via email, understand that TEACCH cannot guarantee the security of the transmission.

If you have any questions regarding the forms or referral process, please contact 919-445-9999 or email Fatima Hedadji at  

    To read Notice of Privacy Practice - English | Spanish 
    General Consent for Treatment - English | Spanish
    UNC Patient Rights - English | Spanish

    If you wish to be able to communicate by email with TEACCH Staff at any point, you must complete and submit this form. Release of Information Form -  spanish version

    Please send all of the completed forms and a copy of client's insurance card to the following address or fax to the number below:

    Raleigh TEACCH Center 
    Attention: Fatima Hedadji
    4301 Lake Boone Trail, Suite 200,
    Raleigh, NC 27607
    Fax: 919-445-0700

    REFERRAL PROCESS and FORMS for Children and Adolescents
     (through age 17)

    REFERRAL PROCESS and FORMS for Adult Client
    (age 18 and older who is NOT his/her OWN GUARDIAN)

    REFERRAL PROCESS and FORMS for Adult Client 
    (age 18 and older who is his/her OWN GUARDIAN)