Healing ECHO Community Member Case

To submit a case, fill out the form below.

Prefer to complete it in your own time? Download this form and email it to the contact listed on the form.

If you have any questions about this case form, please contact echo@npaihb.org.

MM slash DD slash YYYY
Please enter a number from 0 to 120.
(3-4 sentences)

Behavioral Health History

Depression?
Description
Anxiety?
Description
Mania/Hypomania?
Description
PTSD?
Description
Other?
Description

Substance Use History

Illicit Opioid Drugs?
Description
Prescription Opioid Drugs?
Description
Other substances, including alcohol?
Description

Substance Use Disorder Treatment History

Currently receiving Medication Assisted Treatment (MAT)?
Description
Currently enrolled in treatment program or other recovery services?
Description
Has a family violence risk assessment been undertaken?
Has a safety plan been developed with the community member?

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.