Mind Matters ECHO Case Presentation Form
Thank you for your interest in participating in the Mount Sinai Health Partners Mind Matters ECHO! Your participation is vital to our learning community!

Mind Matters ECHO, an application of Project ECHO, was designed to provide a collaborative learning space for clinicians in primary care. We hope that participation in the Mind Matters ECHO clinic, and engaging in case-based discussion, will allow clinicians to feel greater confidence in managing behavioral health conditions that present in primary care. Ultimately, Mind Matters ECHO aims to improve screening and treatment of behavioral health conditions within primary care settings.

Please complete and submit this form as thoroughly as possible. Upon receipt of your case, we will email you to discuss the case presentation further. Case submissions are accepted based on availability of clinic slots and relevance to the presentation topic. We will also reach out to let you know if your submission is unable to be accepted.

Please note:
1. Do not submit Personal Health Information (PHI) about the patient through this form. Only include details about the patient's clinical presentation and needs, as well as your questions, as outlined below.
2. Mind Matters ECHO case consultations do not create or otherwise establish a provider-patient relationship between MSHP and any patient whose case is being presented in a Mind Matters ECHO clinic.

If you have any questions about your submission, please email anitha.iyer@mountsinai.org

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Email *
Provider Information
Please provide the following information about yourself (or the primary treating provider, if you are completing the form on behalf of someone else).
Provider Name *
Provider Email *
Provider Phone Number *
Practice Name *
Reason for Case Presentation
As this is the main focus and purpose of Mind Matters ECHO, please include detail about why you are seeking support with this patient. For example, if you are feeling stuck or that treatment is not working, and/or that you are finding it difficult to engage with the patient and promote treatment gains. The more specific your question, the more value the participants will be able to add.
Why are you seeking support with this case/patient at the present time? (Check all that apply) *
Required
Please elaborate on your main question with this patient. *
Patient Demographic Information
Some information about the patient is essential; it will help participants understand the patient, and promote rich discussion. However, please do not submit Personal Health Information (PHI) about the patient through this form. Only include details about the patient's clinical presentation and needs, as well as your questions, as outlined below.
Patient Age *
Patient Gender *
Who does the patient live with (Check all that apply) *
Required
Patient Clinical Information
Please provide as much detail as possible about the patient's clinical presentation and needs.
Current psychiatric diagnoses *
Current Symptoms of Depression *
Required
If any symptoms of depression are selected in the question above, please elaborate on duration, frequency, and severity.
Symptoms of Anxiety/ Panic *
Required
If any symptoms of anxiety/panic are selected in the question above, please elaborate on duration, frequency, and severity.
Other current psychiatric symptoms
Past psychiatric history *
Current substance use concerns (For any current substances, please provide details on type, method, amount, frequency, and duration). *
Past substance use history *
Suicidality *
Required
If 'Past history of suicide attempts' was selected, please provide details on number of attempts, method(s), circumstances that led to the attempt, and factors that helped patient survive.
If 'Access to lethal means' was selected, please provide details on means, and whether any safety planning around means has been established.
Previous psychiatric hospitalization *
If 'Yes' to psychiatric hospitalization, please provide details about number of hospitalizations, reasons for hospitalizations, and length(s) of stay.
Medical history (Include any relevant medical conditions that impact/are exacerbated by the patient's current psychiatric symptoms and/or ability to access to maintain psychiatric care) *
History of trauma *
Required
Family psychiatric and medical history (If available)
Notable psychosocial and family history (if available)
Current treatment plan for psychiatric conditions *
Current medications (Please include both medical as well as psychotropic medications) *
Past psychiatric medications (Please include both medical as well as psychotropic medications) *
Optional Patient Demographic Information
Please provide the following information if you have it available.
Insurance
Clear selection
Patient Education Level
Clear selection
Patient Employment Status (Check All That Apply)
Patient Occupation
If patient is not presently employed, please indicate patient source of income.
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