Short-Term Clinical Consultation Interest Form

Short-Term Clinical Consultation (STCC) is for children and adults with a diagnosis of autism spectrum disorder. STCC is available throughout all 100 North Carolina counties, as the service is delivered via telehealth.

This service typically lasts 3-4 months. Consultation sessions might be delivered on a weekly or bi-weekly basis, and are faded out across months.

Areas addressed may include: Enhancing structure, organizing and planning the day; promoting independence in daily living routines; practical strategies to build self-advocacy, social communication or emotional regulation skills; and positive behavior support strategies.

This service is not a replacement for direct mental health therapy, ABA therapy, or a formal Behavior Support Plan.

How were you referred to us?*

MCO
Autism Resource Specialist
Self or Family
Autism Society of NC chapter
Physician/Healthcare Provider
Other Provider Agency
Social media post
Other

County of residence (example: Mecklenburg)*

Participant name*

Date of birth*

Age*

Please share your ethnicity:*

Asian
Black/African American
Caucasian/White
Hispanic or Latino
Native American or Other Indigenous
Native Hawaiian or Pacific Islander
Two or More Races
Other/Unknown
Prefer not to answer

Preferred Language in Your Home*

English
Spanish
Other

Autism diagnosis*

Yes
No
Uncertain

Please attach most recent and relevant diagnostic assessments.

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)*

Select All
Innovations waiver
Standard Medicaid
Private Health Insurance
Private Pay

Please enter health insurance company and plan information*

Address (street, city, ZIP code)*

Phone*

Email*

Parent/Guardian(s)*

Relationship to participant*

Briefly describe reason(s) for seeking services*

Today's date*

For additional questions, please contact Melissa Roper (Clinical Intake Coordinator) at mroper@autismsociety-nc.org or 919-390-7242.

*Please update us immediately with any changes to your insurance information, session schedule availability, etc.