Richard Bingham, M.D.




INSTRUCTIONS: New Patient Packet for Richard Bingham, M.D.

Standard Assessment: If you chose this option when we first spoke with you then we have already scheduled your appointment.  If not, call to let us know you would like to schedule.  We will wait to send you materials for steps C. and D. until about two weeks prior to your appointment. Complete what you receive along with step B. and bring all of it to the appointment (or get it to us ahead if you wish).

Rapid Access Assessment: Complete the steps below and send materials back ASAP.  If you did not let us know that you wanted to do the Rapid when we spoke, then call us back to let us know so we can send the materials in C.  The sooner we get a complete Packet back, the sooner we will call back to schedule.  If you have sent the Packet back and not heard from us in three business days then please call.  If you do not think that in the coming week you will get to the several hours of work involved in this Packet, then it might be best to go ahead and schedule a Standard.  We can always move your date up if you turn in all the materials ahead of time.

A. Brief Initial Questionnaire and Agreement: You should have already faxed or mailed

these back to us once you decided to proceed.


B. Print these forms and complete them.

􀀀 Consent

􀀀 Release of Protected Health Information (for primary care physician and therapist)

􀀀 Registration

􀀀 Background Questionnaire

C. Complete the clinical questionnaires you receive in the mail.  For a Rapid return these along with the Forms in B. to us by mail or drop them off in our mail slot M-F, 8 to 5, with the check for $55 (for the Packet costs not covered by insurance).  For a Standard bring all these to the appointment.

D. Once you are scheduled we will send you an appointment confirmation letter (right away for Rapid and two weeks before your appointment for Standard).  A code to complete the ASEBA web-based clinical questionnaire is included for the Rapid (and given to you at the appointment for the Standard).

E. Optional Additional Specific Assessment Questionnaires: These questionnaires are optional. Do only those which may apply to your child based upon diagnoses which have been raised as questions. These require additional time from you and time and materialcosts for me, but are usually well worth it. I list the name of the questionnaire followed in parentheses by the diagnosis on which it is focused, whether the questionnaire is for the parent , the patient (themselves), or a teacher, and lastly for what ages it is designed. Call us to request any of these questionnaires, and we will send them to you.


o MASC (Anxiety; patient, ages 8 to 19)

o CDI (Depression parent, patient, and/or teacher, ages 7 to17)

o Columbia Depression (Depression; parent and/or patient, ages 12 to 21)

o Connerís (ADHD, ODD, Peer Problems; teacher, ages 3 to 18)

o Connerís (ADHD, ODD, Peer Problems; patient, ages 8 to 18)

o Washington University Preschool (Depression; parent, ages 3 to 6)

o C-YBOCS (OCD; parent alone or with child, age 7 and older)

o ASSQ (Autism Spectrum Disorder (ASD); parent or teacher, ages 7 to 18)

o SCQ (ASD; parent, current or lifetime, age 4 and over; mental age > or = to 2)


F. Optional: Write your own description of the problem and history.  This can be extremely helpful and make our time together much more efficient.  Hopefully it is also useful to you as a process of reviewing things in your own mind, and will be available to you in the future as well.


G Optional: Past records: medical, psychological, educational, or other. Get me copies

or have them sent to me. See directions on the website.


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