Rapid Response Clinical Consultation Interest Form

Rapid Response Clinical Consult (RRCC) is for children and adults with a diagnosis of autism spectrum disorder. RRCC is available throughout all 100 North Carolina counties, as the service is delivered via telehealth.

RRCC is a short-term consultation service. Areas addressed to parents/caregivers might include: enhancing structure, organizing and planning the day, quick tips/strategies to address social communication and other skill areas, and behavior intervention strategies.

This service is not intended to address extreme forms of problem behavior or mental health crisis. It is not a replacement for a formal Behavior Support Plan.

Following authorization, consultation service is initiated and is completed very quickly (short-term, 2-4 weeks service duration).

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 Brown (Clinical Intake Coordinator) at mbrown@autismsociety-nc.org or 919-390-7242.

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