Dr. Lulu's Youth Health Center Registration Form
New Patients Only
Email address *
Patient's Name and Phone Number *
Parent(s) Name(s) and Phone number(s) *
Patient's DOB *
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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 *
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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.
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