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Psych Office Hours: Education & Case Consultation

PLEASE NOTE that this case consultation series does not create or otherwise establish a provider-patient relationship between any clinician and any patient whose case is being presented in this series.

Do not share any confidential patient information (name, etc.) when discussing your case during any session.

If your case is chosen, please select a date(s) you are available to attend a session to present.
1.Name:(Required.)
2.Email:(Required.)
3.Please select all availability to present this case:(Required.)
4.What is your reason for presenting this case?(Required.)
5.Please describe your primary concerns regarding the patient’s physical and/or mental symptoms:(Required.)
6.Patient Gender
7.Race/Ethnicity (check all that apply):
8.How long has the child been in your care?
9.Are there any barriers to care? (check all that apply)
10.Payor:
11.Does the child have a history of any of the following? (check all that apply)
12.Is there a history of mental illness?
13.Medication history:
14.Living situation (check all that apply):
15.Family strengths (check all that apply):
16.Performance in school/work:
17.Please describe any other relevant social history concerns or patient strengths:
18.Challenges to care delivery/barriers:
19.Please list any other relevant information you would like to share here: