Referral Form to Dr. Lulu’s Pride Corner

Thank you for referring someone to Dr. Lulu’s Pride Corner.

Dr. Lulu’s Pride Corner is a life coaching and emotional support practice offering identity-affirming care for LGBTQIA+ youth ages 12 and up, and LGBTQIA+ adults.

If you are referring someone who may benefit from affirming coaching and support, please complete this short form. We shall follow up directly with them to share next steps and schedule and introductory connection call if appropriate. Ig it is a parent or caregiver of an LGBTQ+ person, kindly refer them to our MOMM community.

They can call us @ 210-947-9749; we shall take it from there😊

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Email *
Your Full Name *
Your Phone Number *
Who are you referring? *
Required
Kindly share their (preferred) name *

What pronouns does this person use (if known)? 

 *
What kind of support are they seeking? (Checkboxes – choose all that apply) *
Required

Best way to follow up with them (email, phone, etc.)? 

 *

Anything else you’d like us to know?

 *
Thank you!
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