Counseling Techniques: Patient Case Form

Welcome to ECHO Idaho's Online Counseling Techniques for Substance Use Disorder 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 patient/client specific or 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 *

Name of 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

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.

Age

Gender identity

Housing

Education

Employment

Insurance Other, please specify.

Mental health disorders (select all that apply):

Other mental health disorders:

History of trauma or abuse:

Relevant substance use history:

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

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

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

Behavioral health engagement/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.

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