Please answer as many questions as possible, and remember not to share any personal health information (PHI).

If you wish to save your entries and complete the form at another time, click "Save & Return Later" at the bottom of this form. Then enter your email address and use the link you receive to return at your convenience.

By submitting this form, you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between an ECHO clinician and any patient whose case is being presented in a teleECHO session.

For educational and quality improvement purposes, we will be maintaining a Data Repository of all submitted case presentation forms. By submitting this form, you are consenting to the ECHO Institute collecting and housing your case presentation form.

Please contact CHWOpioid@salud.unm.edu, or (505) 925-0856, if you have any questions regarding this form.

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