Please Email to BHA Program Coordinator: bhaecho@salud.unm.edu

Or Fax to: (505)-272-6906, ATTN: Behavioral Health and Addiction ECHO

Behavioral Health and Addiction (BHA) TeleECHO™ Case Presentation Form

Presenter: ☐ New Case

Site: ☐ Follow Up Case Date: Consult Question:

□ Diagnosis ☐ Behavioral Interventions ☐ Medications ☐ Resources

□ Other, please state your question(s):

Patient Information (Please Ensure All Information is De-Identified): Age: Gender: Race/Ethnicity: Relationships: Employment:

Symptoms:

Yes No Housing: Legal Issues:

□ Suicidality □ Self-Injurious Behavior □ Homicidality □ Aggressive Behavior

□ Depression □ Mania □ Hallucinations □ Delusions

□ Anxiety □ Avoidance □ Impulsivity □ Eating Problems

□ Obsessions/Compulsions □ Fatigue □ Nightmares/Flashbacks □ Insomnia

□ Cognitive Problems □ Relationship Problems □ Academic/Work Problems □ Other:

Past Medical History: □ Suicide Attempt(s) □ Self-Injurious Behavior □ Homicide Attempt(s) □ Assault

□ Depression □ Bipolar □ Schizophrenia □ Schizoaffective

□ Anxiety Disorder □ PTSD □ Sleep Disorder □ Obsessive Compulsive

□ Eating Disorder □ Dementia □ Personality Disorder □ ADHD/Learning Disorder

□ Hypertension □ Dyslipidemia □ Obesity □ Diabetes

□ Chronic Pain □ Sleep Apnea □ Thyroid Disorder □ Renal Disease

□ Liver Disease □ Pregnancy/Family Planning □ Other:

Family History: □ Suicide □ Depression □ Bipolar □ Schizophrenia

□ Anxiety □ Substance Use Disorder □ Dementia □ Other:

Substance Use: □ Tobacco □ Alcohol □ Opioids □ Stimulants

□ Cannabis □ Hallucinogens □ Inhalants □ Sedative/Hypnotics

□ Other:

Current Medications:

Primary insurance: Secondary insurance:

Please Email to BHA Program Coordinator: bhaecho@salud.unm.edu

Or Fax to: (505)-272-6906, ATTN: Behavioral Health and Addiction ECHO

Prior Treatment Trials: □ Inpt. Hospitalization □ Inpt. Subs Treatment □ Outpt. Subs Treatment □ 12-Step Recovery

□ General Psychotherapy □ Cognitive Therapy □ Behavioral Activation □ Exposure Therapy

□ EMDR □ SSRI □ SNRI □ Bupropion

□ Mirtazapine □ Trazodone □ Buspirone □ Tricyclic Antidepressant

□ MAOI □ 2nd Gen Antipsychotic □ 1st Gen Antipsychotic □ Gabapentin/Pregabalin

□ Lithium □ Valproic Acid □ Lamotrigine □ Carbamazepine/Oxcarb

□ Stimulant □ Modafinil □ Prazosin □ Cognitive Enhancer

□ Buprenorphine □ Methadone □ Naltrexone □ Benzodiazepine

□ Hypnotic □ TMS □ ECT □ Other:

ROS:

Vitals: Date: Systolic BP: Diastolic BP: Pulse:

Height: Weight: □ lbs. ☐ kgs. BMI:

Exam:

Scales:

PHQ-9: GAD-7: MDQ: MoCA:

Labs: Pregnancy: GFR: AST: ALT:

Albumin: HIV: HCV: T. pallidum AB:

GC/Chlamydia: LDL: HDL: Triglycerides:

HCT: MCV: WBC: ANC:

Drug Screens: Medication Levels: TSH: Other:

Diagnoses: 1. 2. 3. 4.

Plan: 1. 2. 3. 4.