Forms & Fees

The following forms will be useful to download, print, and sign before your first visit:

1. Fill out an intake form for yourself or your child, and bring it with you for your visit.

Download Intake Form

2. Review these forms, sign, and bring with you for your visit: Consent form, Notice of Privacy Practices, Notification of Scope of Practice

Download and Sign Consent Form

Download and Sign Scope of Practice Notification Form

Review Notice of Privacy Practices

 

 

Policies

Cancellation Policy: We require 24 hours notice to cancel appointments and incur no fee. If you cancel within 24 hours , you will be charged a $50 cancellation fee. Missed appointments will be charged the full cost of the appointment.

PIP (Personal Injury Protection) Claims: We accept PIP claims for auto accidents. Please provide the following information before your first appointment:

  • Date of accident
  • Claim number
  • Insurance claims adjuster’s contact information
  • Attorney’s contact information (if applicable)

Superbills/receipts: We are happy to provide a receipt which you can submit to your insurance company for reimbursement. Please check your healthcare plan to make sure you have coverage for acupuncture and out-of-network provider coverage.

For Acupuncture visits, you do not need a prescription. I can provide the diagnosis and information needed on your superbill / receipt.

If you would like a Superbill for Craniosacral treatments, you will need a Massage Prescription dated prior to the first date of service. Insurance billing requires a medical diagnosis and currently Massage Therapists cannot diagnose for a medical condition. Even though it is in my scope of practice to diagnose certain conditions for Acupuncture, I cannot diagnose when doing Craniosacral / Massage Only Treatments.

Fees:

First Acupuncture Visit: $125

Includes health history / intake + treatment. Other modalities used include: cupping, “moxa” (moxibustion), acupressure, gua sha, and craniosacral. Allow 60 to 90 minutes for first visit.

Acupuncture Return Visits: $100

Allow up to 60 minutes for return visits.

Pediatric Return Acupuncture Visits (depending on age): $60

Generally 30 minutes for pediatric return acupuncture visits.

First Craniosacral Visit: $120

Craniosacral Return Visit: $120

Combined Sessions: Acupuncture + Craniosacral Return Visits:

these visits can range from $100 – $140, depending on modalities and units of time.