Case Presentation Form

This form is intended for healthcare or social service providers to bring a case presentation to any upcoming ECHO session.

Case presentations are held at the end of each ECHO session and they are a time for participants to talk about a challenging patient or client. The purpose of case presentations is to offer relevant support to each other and to share knowledge and experience.

Note: all personally identifying information about the patient or client is prohibited.

After submitting this form, a member of our ECHO team will reach out to you within three business days.

Thank you for your interest!

Question Title

* 1. Your Information

First and last name (include credentials)

Title

Organization

Email Address

Question Title

* 2. Date of Client/Patient Encounter (if known)

Date / Time

Date

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* 3. Patient/client age:

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* 4. Sex assigned at birth:

Female

Male

Intersex

Unknown

Other

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* 5. Gender

Nonbinary

Transgender

Two Spirit

Female

Male

Genderqueer

Genderfluid

other

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* 6. Race (check all that apply)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Unknown

Another race

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* 7. Insurance (check all that apply)

Medicaid

Medicare

Program HH

Commercial

None

Other

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* 8. Are they currently pregnant?

Yes

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* 9. What is their housing status?

Unknown

Temporary

Stable

Unstable

Unsheltered

Case Presentation Form

Question Title

* 1. Your Information

Question Title

* 2. Date of Client/Patient Encounter (if known)

Question Title

* 3. Patient/client age:

Question Title

* 4. Sex assigned at birth:

Question Title

* 5. Gender

Question Title

* 6. Race (check all that apply)

Question Title

* 7. Insurance (check all that apply)

Question Title

* 8. Are they currently pregnant?

Question Title

* 9. What is their housing status?

Question Title

* 10. Briefly describe the situation. Specify what questions you have, what feedback you are looking for, and from whom.