Specialized Consultative Service (SCS) referral

Please complete the following form fields and click submit to share client information and be considered for Specialized Consultative Service with the Autism Society of North Carolina Clinical Team.

Your Name*

First Last

Your Phone*

Your Email*

What is your affilation/role?*

MCO representative
Other Provider Agency
Autism Resource Specialist
Internal referral (Regional or Program staff)

County of residence for the referred (example: Mecklenburg)*

Participant name*

Date of birth*

Age*

Preferred Language in Referral Home*

English
Spanish
Other

Autism diagnosis*

Yes
No
Uncertain

Please attach most recent diagnostic assessments and ISP/PCP.

Drop files here or

Max. file size: 300 MB.

Acceptable formats include: PDF, Word Doc, JPG, PNG, and GIF

Funding source for service (check all that apply)*

Innovations waiver
Other

Select the referred individual's MCO*

Briefly describe reason(s) for seeking services*

Today's date*

For additional questions, please contact Whitney Sukonick (Clinical Director) at wsukonick@autismsociety-nc.org.

*Please update us immediately with any changes to your situation or needs.