Counseling Techniques for Substance Use Disorders: Patient Case Form

Welcome to ECHO Idaho's Online Counseling Techniques for Substance Use Disorders Case Submission Form.

Please complete as much of the form as you can. We understand you might not have all the data. Please do not include any patient/client specific, Personally Identifiable Information (PII) nor Protected Health Information (PHI). If you have any questions regarding this form, please contact echoidaho@uidaho.edu.

Presenter First and Last Name *

Credentials

Email *

Phone number *

Organization

City, State *

ECHO Idaho offers $100 in compensation for case presentations. Would you like to accept compensation for presenting this case? *

Yes (ECHO staff will reach out to you with compensation paperwork that must be completed three weeks prior to your presentation date.)

No, I would like to donate my time.

Please do not include any identifiable patient/client information, Personally Identifiable Information (PII), or Protected Health Information (PHI) or information protected by The Family Educational Rights and Privacy Act (FERPA). If you have any questions regarding this form, please contact echoidaho@uidaho.edu. *

Click here to acknowledge.

Please indicate if this is a new patient/client case or if this is a follow-up to a previously presented case. *

New patient/client case

Follow-up to a previously presented case

Are you willing to present a follow-up on this case in 3 months?

Yes

No

Maybe

I am looking for (select all that apply):

Help with diagnosis

Help with treatment options

Help with referrals

Social Determinants:

Age

Gender identity

Housing:

Education:

Employment:

Insurance: Other, please specify.

History of trauma or abuse:

Mental health disorders (select all that apply): Other, please specify:

Behavioral health engagement/treatment (select all that apply):

Behavioral health engagement/treatment (select all that apply): Other, please specify:

Please include any relevant substance use history:

Please include any other relevant medical history (family history, hospitalizations, surgeries, injuries, etc.):

Please include any other relevant social history (client strengths, cultural factors, support systems, criminal justice system status, etc.):

Client goals for treatment:

Provider goals for treatment:

What specific treatment questions do you have for ECHO?

What progress has your patient/client made since your initial presentation?

Have you or the patient/client encountered any additional challenges or obstacles since you presented the case? If so, what were they?

What does the client hope to achieve next?

What do you hope to achieve next?

What follow-up questions do you have for ECHO?

Thank you for completing ECHO Idaho's Counseling Techniques for Substance Use Disorders Case Submission Form:

Case consultations do not create or otherwise establish a provider-patient relationship between any clinician and any patient whose case is being presented in this clinical setting.
No personally identifiable health information (PHI) or personally identifiable information (PII) appears in answers on the above form, in compliance with HIPAA privacy laws.

You will receive a copy of your responses in the email you provided and be contacted by ECHO staff about presenting your case in a session or follow-up consultation with a panelist within two business days.

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Counseling Techniques for Substance Use Disorders: Patient Case Form