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Project ECHO at Tulane University Case Presentation Form - MAT

Please read this information before filling this form. Please be sure that you have already received an approval from signing up on this site. You can find more information about Medication-Assisted Treatment (MAT) here. You will be assigned an ECHO ID for each patient case presented though email once your case has been preliminarily approved.

We'll never share your email with anyone else.
New patient
Patient's gender

Substance Use

Substance Use
Previous
Current
History
Heroin
Previous?
Current?
Methamphetamine
Previous?
Current?
Alcohol
Previous?
Current?
Opiates
Previous?
Current?
THC
Previous?
Current?
Cocaine
Previous?
Current?
Fentanyl
Previous?
Current?
Misuse of Rx
Previous?
Current?
Misuse of OTC
Previous?
Current?
Nicotine
Previous?
Current?

Current MAT Therapy

Treatment Method
Previous
Current
Dose
Naltrexone
(ReVia, Vivitrol, Depade)
Previous?
Current?
Disulfiram
(Antabuse)
Previous?
Current?
Acamprosate Calcium
(Campral)
Previous?
Current?
Methadone
Previous?
Current?
Buprenorphine
(Suboxone, Subutex, Zubsolv)
Previous?
Current?
Varenicline
(Chantix)
Previous?
Current?
Bupropion
(Zyban, Wellbutrin)
Previous?
Current?
Labs
Co-occurring Mental Health Disorders

Family History of Mental Health or Substance Use Disorders

Diagnosis
Relationship to patient
Behavioral Health Engagement

Current Medications

Medication
Dose
Required for
Criminal Justice System Status
Insurance Type

PLEASE NOTE: Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between any panel member and any patient whose case is being presented in a project ECHO setting. Always use ECHO ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.