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System of Care ECHO Consultation Form*Do Not Include Any Personal Identifiers (PHI)*
Clinician name: Click or tap here to enter text. Email: Click or tap here to enter text. Phone: Click or tap here to enter text. ECHO ID: SOC# Age: Gender: Race/Ethnicity:
Diagnoses (MH/SU/DD) Current:
Historical:
Medications Current:
Historical:
Priority Question(s) for SOC Project ECHO Consultation
1.
2.
ECHO presentation structure, to be guided by facilitator:1. Facilitator will guide you through your presentation by asking about strengths, barriers, and needs/concerns
in each of the life domains above. 2. Be ready to discuss the youth and caretaker(s)’ top 3 strengths, assets and/or connections/supports. 3. Be ready to summarize the priority concerns/issues you are bringing forward for Project ECHO consultation. 4. Keep the consultation targeted: If this consultation is successful what knowledge will be gained?
SOC ECHO Consultation Form V 6-1-2020
Consultation Information
System Involvement: ☐ MH ☐ Child Welfare ☐ IDD ☐ School (IEP) ☐ Substance Use ☐ FCFC ☐ Court
School Placement: ☐ ED ☐ LD ☐ OHI ☐ DH Grade Level:
Custody/Caretaker (no names):
Other Household Members (no names):
Domain Priority Concerns/Needs Barriers Strengths
Individual/Developmental
Home/Family
School
Community (legal, peers,
activities)
Cultural and Religious
Identification
Health Concerns
Risk & Safety Issues
SOC ECHO Consultation Form V 6-1-2020
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