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Call 570.629.4900 Today! | 1801 West Main Street, Stroudsburg, PA 18360

Dr. Dustan A. Barabas, P.C.

Clinical Psychologist

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Patient Registration Form

Please fill out the form below to help expedite your registration process. All information submitted through this form is securely transmitted to our private email account and is never stored on our website.

Personal Information

Name *

First

Last

Phone *

Email *

Emergency Contact Name *

Emergency Contact Phone *

Address

Address Line 1

City

State

Zip Code

Age *

Sex *

Male
Female

Employment Status *

Yes
No
Disability
Retired

Marital Status *

Married
Single
Other

you charge of

Spouses Name *

Time Preference for Service *

Morning
Afternoon
Evening

May we contact you via email? *

Yes
No

How were you referred?

Online
Friend
Healthcare Provider
Insurance
Other

Type of Services Requested *

Individual Therapy
Family Therapy
Marital/Couples Therapy
Group Therapy
Psychological Testing
Psychological Consult
Substance Abuse Counseling
Other

Brief description of reason for seeking services *

Are you currently experiencing suicidal thoughts or desire to harm yourself or others? *

Yes
No

Are you seeking medication? *

Yes
No

Any criminal or legal issues? *

Yes
No

Are you seeking services for social security disability determination or other social security disability matters? *

Yes
No

Are you having any drug or alcohol problems? *

Yes
No

Have you ever been hospitalized for a mental health related condition? *

Yes
No

Are you currently prescribed any psychotropic medications such as antidepressants? *

Yes
No

Are you planning to self-pay cash check or charge at the time of service? *

Yes
No

Psychotherapy self-pay prices range from $100.00 to $150.00

Health Insurance Information

Health Insurance Plan Name

Policy Holder / Member Name

Dependent Name

Health Insurance ID Number

Group Number

Deductible / Co-pay

Upload a picture of your driver’s license and insurance card.

Click or drag files to this area to upload.You can upload up to 2 files.

Maximum file size 5MB

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Call 570.629.4900

1801 West Main Street, Stroudsburg, PA 18360

Patient Registration

Telehealth Consent

Have a Question?

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Phone *

Comment or Message *

If you want to register click the button below to complete the Patient Registration form.

Patient Registration

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