Dr. Lulu's Youth Health Center Registration Form
New Patients Only
Sign in to Google to save your progress. Learn more
Email *
Patient's Name and Phone Number *
Parent(s) Name(s) and Phone number(s) *
Patient's DOB *
MM
/
DD
/
YYYY
Home Address *
What grade is your child in? *
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 *
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 *
MM
/
DD
/
YYYY
Please note; upon completion of this form, you will receive an email with links to some screening forms and more information. Ensure that your child/teen completes the PHQ-9 and the ACEs questionnaire by themselves. The other two forms are for parents. Thank you.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms