Dr. Lulu's Youth Health Center Registration Form

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New Patients Only

Email *

Untitled Question *

Option 1

Patient's Name and Phone Number *

Parent(s) Name(s) and Phone number(s) *

Patient's DOB *

Option 1

Home Address

What grade is your child in? *

Freshman

Sophomore

Junior

Senior

What is the reason for signing your child up? *

Who is your child's previous doctor/counselor? *

What forms of treatments have been tried? Did they work? *

Would you like to sign up for a membership today? If yes, have you looked at the "our fees" page on our website? https://youthhealthcenter.com/our-fees *

Yes

Click this calendar link to schedule your first appointment. You may also call Dr. Lulu for your FREE phone conuslt by dialing 802-768-1180. https://calendly.com/teenalive/appointments *

Click each of these links to fill out the patient registration forms. PS: Please ensure that your child/teen completes the PHQ-9 and the ACE questionnaire by themselves. The other two forms are for parents. Thank you. 1/ PHQ-9: https://drive.google.com/file/d/18IxzRHVjNoG8at16PU1zNOgbxSzjkf0u/view?usp=sharing 2/ Medical Record Release: https://drive.google.com/file/d/1YMMqOw9qy0wy5MzwiRgNLH54f760qHDu/view?usp=sharing 3/ ACE: https://drive.google.com/file/d/1U30puD4UsyMp8F2asCFyJ2iWGYY29a2N/view?usp=sharing 4/ Patient Agreement Form: https://drive.google.com/file/d/1PnLKWxAyw2xwOmbJiwWLE1JNDSRKpFBM/view?usp=sharing *

Option 1

I look forward to meeting you and your child over Zoom. Thank you. *

YYYY

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