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