LIBRATUM COUNSELING, LLC                   142 W. Market St., 2nd Floor

610.616.5890                                                                                                          West Chester, PA 19382

Client Information

DATE:_______________

NAME:_________________________________________________   Date of Birth:______________________  

ADDRESS: ______________________________________________________APT:_______________________

_____________________________________________________________________________________________

(City)                                (State)                                (Zip Code)

Email:_______________________________________________________________________________________

Mobile telephone:________________________Home telephone:____________________________________

Employer/School:_________________________________Occupation:_______________________________

Who Referred you to Libratum Counseling, LLC :_____________________________________________

RESPONSIBLE PARTY INFORMATION

Parent(s) or Spouse Name:___________________________________________________________________

Employer(s):_________________________________________________________________________________ Occupation(s):_______________________________________________________________________________

Mobile Telephone: ____________________________Home Telephone: _____________________________

Email:_______________________________________________________________________________________

EMERGENCY CONTACT

Name:___________________________________Relationship to Client: _____________________________

Address:_____________________________________________________________________________________

Mobile Telephone: ______________________________Home Telephone:____________________________

Email: ______________________________________________________________________________________