Fillable Bh Case Presentation Form (University of Wyoming)

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Bh Case Presentation Form (University of Wyoming)

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Page 1 of 2
Please complete ALL ITEMS on the form and email to UW ECHO at
projectecho@uwyo.edu.
Thank you.
Behavioral He
alth
Case Presentation Form
Presentation Information
Presentation occurrence:
Case type:
Presenter’s first and last name:
Presenter’s phone number:
Presenter’s email address:
Proposed dates for initial presentation:
First proposed date:
Second proposed date:
Third proposed date:
***OFFICE USE ONLY***
ECHO ID:
Date:
Whe
n we receive your case, we will email you a confidential identification number (ECHO ID) and confirm date and
time
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 will 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.
Please, select one
Please, select one
Page 2 of 2
Case Information
1. What is your professional role (check all that apply)?
Check all that apply:
2. What is the current status of the individual or program?
3. Please identify the primary concern and goal for this case presentation.
4. Describe contributing factors that may have kept the individual or program from progressing to the desired
level.
5. For Individual Cases Only:
What are common triggers, stressors, and/or factors related to the priority concern?
6. For Program Cases Only:
What are the strengths, challenges, opportunities, and threats of your program?
7. What are some of the integrative care strategies that have been tried with this client, and how successful
have they been?
8. Comments or additional background narrative.
What else should the team know in order to provide feedback and recommendations?
☐
Case manager
☐
Judicial System Representative
☐
☐
Counselor
☐
Law Enforcement
☐
☐
Court Supervised Treatment Staff
☐
Nurse
☐
☐
Peer Specialist
☐
☐ Educator
☐ Other:
***OFFICE USE ONLY***
ECHO ID:
Date:
Updated:
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Completed 16 July 2020

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