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Department of Psychiatry and Behavioral Sciences

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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.

Substance Use

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

Current MAT Therapy

Treatment Method
Previous
Current
Dose
Naltrexone
(ReVia, Vivitrol, Depade)
Disulfiram
(Antabuse)
Acamprosate Calcium
Campral)
Methadone
Buprenorphine
(Suboxone, Subutex, Zubsolv)
Varenicline
(Chantix)
Bupropion
(Zyban, Wellbutrin)
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
Clear/Cancel

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.