Page 1 of 2
Please complete ALL ITEMS on the form and email to UW ECHO at
projectecho@uwyo.edu.
Thank you.
Organization Team Information
Team Member Role:
Team Member Role:
Team Member Role:
Assistive Techn
ology
Case
Presentation Form
Wh
en we receive your case, we will email you a confidential identification number (ECHO ID) and confirm date and
tim
e for the case presentation. The provided ECHO ID must be utilized when identifying this case presentation
during the ECHO Session. Case presentation times may fluctuate depending on the availability of the professional
de
velopment presenter. Times wi
ll be confirmed when the ECHO ID is assigned.
PLEASE NOTE: The UW ECHO case consultations do not create or otherwise establish a relationship between any of
the UW ECHO experts or UW ECHO staff and any participant whose case is being presented in a UW ECHO setting.
The information provided as feedback are considerations only and not a formal assessment.
Presenter’s first and last name:
Presenter’s phone number:
Presenter’s email address:
Proposed date for initial presentation:
***OFFICE USE ONLY***
ECHO ID:
Date:
I Date:
Team Member Role:
Team Member Role:
Team Member Role:
Additional Information:
Please fill out the team member staff roles who are involved working with the client. Names are not necessary.
