Adolescent Case Presentation Form

General Information/Demographics

Please enter a number less than or equal to 125.
Gender Identity

Race/Ethnicity (check all that apply):
Insurance

Presenting Concerns

Relevant Medical/Psychiatric History

Current Medications

Psychosocial & Developmental History

Substance use history (alcohol, cannabis, nicotine, others):
Trauma/ACEs history:

Risk Screening

Risk Screening

Reproductive & Sexual Health

Social Determinants of Health

Housing stability:
Transportation access:
Food security:
Access to culturally relevant community supports:

Current Strengths and Protective Factors

Key Questions for ECHO Faculty & Participants

Please be specific about what you would like feedback on – e.g., diagnosis clarification, treatment options, care coordination, community resources:
Topic Selection (highlight/circle all relevant topics)

By submitting this form, you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between an ECHO clinician and any patient whose case is being presented in a teleECHO session. Always use Patient ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.