Pediatric Psychiatry in the Primary Care Setting ECHO


Case Presentation Form:

Case presentations serve as a platform for our group to share best practices, innovative ideas, and local resources. We encourage you to submit a de-identified patient case that is presenting a challenge to you.


Please ensure that you respect your organization’s HIPAA obligations as you enter your case.



Please email sbillings@mcd.org, if you have any questions regarding this form.

Your Information:

Case Presentation Type: Original or Follow Up?

Only change to Follow Up Presentation if you have already presented.

Your Case

Please provide the group with information they should know in order to provide feedback and recommendations.


It is important to have one or two key questions for the group. It is not important to fill out every box.


Please do not share any Protected Health Information (PHI)

Please provide one or 2 key questions for the group.

Section 1

Non-identifiable Patient Information

if known

Are there cultural, linguistic, spiritual, or community values that may influence how the patient or family understands and engages with care? (Beliefs about health and behavior, family roles, stigma, help-seeking practices, or communication preferences)

Section 2

Summarize

Include current symptoms, diagnosis and treatment, if any.

Section 3

History and Screenings – Key Findings

if available

(Activities, relationships, academics, routines)

(trauma, social, academic, behavioral, developmental, substance use)

Section 4

Medications & Treatments

(Rx, PRN, OTC, Herbals, etc)

Section 5

Additional Connections

(therapist, case manager, psychiatrist, legal system, community agencies...)

Thank you for completing the Case Presentation form

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