Forms

 

Keystone requires that you maintain current information during your time as an active client. In order to allow you to review this information in the privacy of your own home, Keystone has provided blank forms for you to print. Just click on the name of the form below and a separate window will appear for easy printing.

 

Prior to your first appointment, or any time your status changes, Keystone request you follow these three easy steps in order to print these forms, complete them in full, and bring them with you to your appointment. 

 

1. Patients should READ the following three forms: Keystone New Client Instructions, Keystone Disclosures Statement, and Keystone HIPPA Compliance, prior to completing the required paperwork.

 

Keystone New Client Instructions
Keystone Disclosure Statement
Keystone HIPPA Compliance

 

2. ALL Patients being seen by a therapist should PRINT and COMPLETE the following three forms: Keystone Client Information Sheet, the Keystone Consent for Treatment Form, and Keystone Financial Policy prior to arriving at your first appointment. Note that ALL patients receiving counseling in a therapist's office must individually sign a separate Consent for Treatment form which may require you to print multiple copies.

 

Please open the following editable forms, COMPLETE and PRINT. Complete all three forms.

 

Keystone Client Information Sheet
Keystone Consent for Treatment Form
Keystone Financial Policy Form

 

3. Patients should PRINT and COMPLETE the appropriate form below depending on the type of service received. Choose one form to print and complete.

 

Patient Form for Individual Adult
Patient Form for Minor Child Dependent
Patient Form for Married Couples
Patient Form for Partners

 

Please arrive at your first appointment with FOUR completed forms. 

 

PLEASE NOTE - Keystone is a consortium of independent practitioners licensed in South Carolina and each provider operates as an independent contractor under a separate Limited Liability Company. Payments will be made directly to provider at time of service and checks will be made out to independent therapist Limited Liability Corporation. Make check payable to:

 

"Keystone" for Dana Saunders
"Middle Path Therapy Center" for Jim Moran

 

Clients are expected to make payment in full at the time of service.

 

We sincerely thank you for taking time in advance to prepare for your first meeting. Keystone provides these forms online because we are dedicated to optimizing your time with the therapist in order to provide you the best care available. 

 

Additionally, we encourage you to browse the Keystone website for answers to your many questions.

 

Welcome to Keystone