Opioids: Patient Case Form

Welcome to ECHO Idaho's Online Opioid, Pain, and 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 specific client specific of 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 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

Did the advice you received from the ECHO panelists in your initial presentation change the way you approached this case? If so, in what ways? If not, why not?

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

In today's session, I'm looking for: *

Help with diagnosis

Help with medications

Help with non-medication treatment

Other, please specify.

In today's session, I'm looking for: Other, please specify.

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.

Age

Gender identity

Housing

Education

Employment

Insurance Other, please specify.

Relevant substance use history:

Relevant psychiatric history:

Current medications (include dose and length of time used):

Past medications (include dose and length of time used)

Medication adherence (select one)

Excellent

Good

Fair

Poor

Please include any relevant socio-cultural information (patient/client strengths, cultural or religious factors, support systems etc.)

Please describe any social determinants of health that may provide additional context for this case. *

Substance use or behavioral health engagement or treatment (select all that apply):

Residential treatment

Individual therapy

Group or family therapy

Alcoholics/Narcotics Anonymous

Other, please specify.

Substance use or behavioral health engagement or treatment (select all that apply): Other, please specify.

Patient/client goals for treatment: *

Provider goals for treatment: *

Current/proposed treatment plan:

What specific treatment questions do you have for ECHO? *

Thank you for completing ECHO Idaho's Behavioral Health in Primary Care 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.

Please describe any relevant trauma history (physical, emotional, or sexual abuse; physical or emotional neglect; interaction with the criminal justice system; experiences being unhoused, etc.)

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