Service Terms and Agreements
Service Terms and Agreements are best viewed on a computer,
not a mobile device.
If you would like any documents emailed to you, contact connect@sunsetmothwellness.com.
Financial and Scheduling Agreement-Massage Therapy Sessions
Sliding scale:
Massage prices are on a sliding scale. Pay what works for you for each massage session. Note that initial appointments are longer and cost more to account for intake processing (time spent creating a plan with the client and administrative work).
No need to tip:
Sunset Moth Wellness (SMW) does not accept gratuity (tips) for massage services. Here at SMW, massage therapy is viewed as any other healthcare service you receive. If you would like to further support SMW's community at large and have the means, choose to pay more than the minimum on the sliding scale. This helps continue the ability to provide a sliding scale so others who cannot pay more than the minimum can still receive services while keeping SMW thriving.
Booking deposit:
Secure your appointment by paying a $50 security deposit, which will go towards your total service charge. You will then pay the remainder of your balance at time of service.
If you choose not to pay in full at time of booking, this deposit is due to secure your appointment to account for a less than 24-hour cancellation or rescheduling fee. (See the cancellation/rescheduling section below for more details.)
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Payment processing:
All payments will be processed on Sunset Moth Wellness (SMW)'s online scheduler, Practice Better via the payment transaction software, Square.
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Canceling or Rescheduling MORE than 24 hours before your appointment:
If you cancel your appointment more than 24 hours in advance, a refund request will be sent to SMW. If your refund is approved, expect a refund on the payment card you used within 3-5 business days.
If you reschedule an appointment for the same amount of time, then your payment will roll over for each appointment you reschedule. If you would like to reschedule for a different amount of time, you will need to cancel your current appointment(s), and then book the new time amount. Expect the refund from your original appointment(s) within 3-5 business days.
Canceling or Rescheduling LESS than 24 hours before your appointment:
If you cancel or reschedule an appointment less than 24 hours before the appointment begins, your $50 deposit becomes a cancellation/late rescheduling fee. Exceptions may be made on a case-by-case basis.
Rescheduling LESS than 24 hours for an appointment for the same day, but a different time exception:
If you reschedule your appointment less than 24 hours in advance, but it is for another time on the same day as your original appointment, there will be no late rescheduling fee, and your deposit will roll over to your new appointment.
Trying to reschedule an appointment, but there are no future time slots available:
If you would like to reschedule but there are no future time slots available or time slots that would work with your schedule, please cancel your appointment and join the waitlist. If you are owed a refund, expect it on the payment card you used within 3-5 business days.
If Sunset Moth Wellness cancels your appointment:
If Adrienne needs to cancel your appointment for any reason at any time, you will be issued a full refund. Expect a refund on the payment card you used usually within 3-5 business days.
FSA/HSA Accounts:
You may be eligible to use your FSA or HSA account for Services at Sunset Moth Wellness (SMW). Depending on the rules of your account, you may need a medical diagnosis and a recommendation letter from your medical provider to do so. SMW can always work with you and your medical provider to submit the appropriate information.
If you have any questions about this financial agreement please contact Adrienne at connect@sunsetmothwellness.com.
Last updated: Septmeber 2024
Financial and Scheduling Agreement-Wellness Support Sessions
Payment:
You have the option to pay in full upon booking or to pay a deposit of half the cost, and then pay the other half anytime before the start of your appointment. Your payment will be processed on Sunset Moth Wellness (SMW)'s online scheduler, Practice Better via the payment transaction software, Square.
Paying in installments:
Practice Better automatically saves payment information when you choose to pay in installments (making a deposit upon booking instead of paying the full amount). If you do not want your payment information saved, you can go into your client portal to delete it. (You will receive an email invitation to set up your portal.)
Once in your portal, click on “Invoices and Billing". Then click on the “Billing Information". There you will see your saved payment information. Click the three dots and you will see the option to delete this information. In the "invoice" tab you will see the invoice for your second installment, which will need to be paid before your appointment can begin. If you need help with this process, contact Adrienne via connect@sunsetmothwellness.com or via the Practice Better Messaging tool.
Canceling MORE than 24 hours before your session:
If you cancel a session more than 24 hours in advance, a refund request will be sent to SMW. Expect a refund on the payment card you used usually within 3-5 business days.
Canceling or Rescheduling LESS than 24 hours before your session:
If you cancel or reschedule a session less than 24 hours before the session begins or fail to show up, you will be charged 50% of the total cost of the service. If you paid the entire cost, expect a 50% refund on the payment card you used within 3-5 business days.
Trying to reschedule an appointment, but there are no future time slots available:
If you would like to reschedule but there are no future time slots available or time slots that would work with your schedule, please cancel your appointment and join the waitlist. If you are owed a refund, expect it on the payment card you used usually within 3-5 business days.
If Sunset Moth Wellness cancels your appointment:
If Adrienne needs to cancel your appointment for any reason, you will be issued a full refund. Expect a refund on the payment card you used within 3-5 business days.
FSA/HSA Accounts:
You may be eligible to use your FSA or HSA account for Services at Sunset Moth Wellness (SMW). Depending on the rules of your account, you may need a medical diagnosis and a recommendation letter from your medical provider to do so. SMW can always work with you and your medical provider to submit the appropriate information.
Last updated: September 2024
Financial and Scheduling Agreement-Private Group Class or Customized Workshop-Organizers
Payment:
The minimum amount owed is $90 for six or less participants per hour. It costs an additional $15 for every participant beyond six per hour. You can pay one total invoice or have participants pay separately.
There is a building, travel, and set-up fee totaling $60 for 1-4 hours and $100 for 5-8 hours if you choose to host your class or workshop in person. Others fees may apply depending on your chosen in-person location.
Paying by one invoice:
If you choose to pay one invoice, Sunset Moth Wellness will email you an invoice for the total amount due. It is due in full at least 48 hours before the start of the class to secure your booking otherwise the event may be canceled and if owned a refund, you can expect it usually within 3-5 business days.
If participants you have paid for do not come, you will be entitled to a refund of the agreed-upon amount per participant minus the minimum retainer of $90 per hour plus the Building, Travel, and Set-up fee, if the event is in person, and additonal fees that may occur depending on your chosen location.
Each participant pays separately:
If you have chosen to have each participant pay separately, participants will pay for the event during the registration process via Practice Better after an agreed-upon amount is set to charge each participant. You have the option to pay the Building, Travel, and Set-up fee via a separate invoice sent to you or it can be distributed to all participants, which you can select on the request form. A minimum of $90 per hour plus the Building, Travel, and Set-up fee, if the event is in person, and potentially any other fees depending on your chosen in-person location, must be received at least 48 hours before the start of the class to secure your booking. If the minimum amount has not been paid on time, your class will be canceled and your reservation time and date will no longer be available to you. You as the organizer may request an invoice to pay the difference before the 48-hour mark.
Canceling or Rescheduling LESS than 48 hours before your class or workshop after you've paid:
If you cancel or reschedule your entire event less than 48 hours before the class begins there will be a $90 cancelation or late rescheduling fee. If you paid by invoice, you can expect a refund less the fee on the payment card you used usually within 3-5 business days.
If participants have paid separately, the organizer must ensure the fee is paid before Sunset Moth Wellness issues any refunds. Once the fee has been confirmed, each paid participant can expect a full refund on the payment card they used usually within 3-5 business days.
Canceling or rescheduling MORE than 48 hours before your class or workshop after you've paid:

If you canceled or rescheduled MORE than 48 hours before your class or workshop, and you have paid by invoice, expect a full refund on the payment card you used usually within 3-5 business days. If participants have paid separately, they each can expect a full refund on the payment card they used usually within 3-5 business days.
If Sunset Moth Wellness cancels your class:
If Adrienne needs to cancel your event for any reason, you and your participants will be issued full refunds. Expect refunds usually within 3-5 business days.
Copy of the Scheduling and Financial Agreement for Participants:
Your group organizer has either opted to pay the entirety of the payment via one invoice or for each participant to pay separately. If the organizer has opted for participants to pay separately, payment is due to complete this registration and the amount will be noted on the payment page.
If the the agreed-upon retainer between the organizer and Sunset Moth Wellness has been met, and you are not able to attend the class, but you have paid, expect a refund from Sunset Moth Wellness usually within 3-5 business days.
If the retainer has not been met, you may not be owed a refund. This will be dependent on the final agreement between the organizer and Sunset Moth Wellness, which will be communicated to you by Sunset Moth Wellness before the class or workshop.
Also note that if the agreed-upon retainer amount between the organizer and Sunset Moth Wellness has not been paid at least 48 hours before the start time of the class, the class will be canceled. If you have already paid, expect a refund from Sunset Moth Wellness usually within 3-5 business days.
Last updated: Septmeber 2024
Financial and Scheduling Agreement-Private Group Class or Customized Workshop-Participant
Your group organizer has either opted to pay the entirety of the payment via one invoice or for each participant to pay separately. If the organizer has opted for participants to pay separately, payment is due to complete this registration and the amount will be noted on the payment page.
If the the agreed-upon retainer between the organizer and Sunset Moth Wellness has been met, and you are not able to attend the class, but you have paid, expect a refund from Sunset Moth Wellness usually within 3-5 business days.
If the retainer has not been met, you may not be owed a refund. This will be dependent on the final agreement between the organizer and Sunset Moth Wellness, which will be communicated to you by Sunset Moth Wellness before the class or workshop.
Also note that if the agreed-upon retainer amount between the organizer and Sunset Moth Wellness has not been paid at least 48 hours before the start time of the class, the class will be canceled. If you have already paid, expect a refund from Sunset Moth Wellness usually within 3-5 business days.
Last updated: September 2024
Consent of Care-Wellness Support Sessions
HIPAA/Personal Healthcare Rights/GDPR Rights Notices- All Services
Financial Agreement: Gift Certificates
Age for Purchasing
You must be at least 18 years of age or older to purchase a gift certificate.
Refunds
A refund can be issued up to 48 hours after purchase, as long as a service has not been booked using any amount of the gift certificate. After the 48-hour time period and/or after a client has booked a service using the gift certificate, no refund will be offered.
Expiration
Gift certificates are valid for 1 year from date of purchase.
Statement of Risk
You absorb the risk that Sunset Moth Wellness could go out of business before your recipient uses their gift. Sunset Moth Wellness cannot guarantee that the same services available at the time you purchased the gift certificate will still be available once the person you have purchased the gift certificate for is ready to use it.
Last updated: June 2024
Consent of Care-Wellness Support Sessions
The following agreement is for the health and safety of both the client and the practitioner, Adrienne Banks.
Adrienne Banks agrees to the following rules of care, and to receive a service, you must also consent to the following rules of care.
You, the client or legal guardian of a client under the age of 18, understand that:
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Adrienne Banks is not a medical doctor or licensed mental health clinician. She cannot diagnose health conditions, prescribe pharmaceutical medication, or clinically manage any medical diagnosis including a mental illness diagnosis. Any services rendered by Adrienne Banks should not be construed as a substitute for medical examination, diagnosis, or treatment. Services at Sunset Moth Wellness may compliment treatment by a medical doctor or clinical therapist, and Adrienne Banks can collaborate with a client's other healthcare providers with consent.
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A service can be stopped by the client at any time without needing to give an explanation to Adrienne Banks.
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Adrienne Banks has the right to refuse or discontinue care if she believes the relationship with a client to be a conflict of interest, unhealthy, or unsafe for her at anytime. A refusal of care statement will be sent to the client, but an expressed purpose may not be stated in order to protect Adrienne Banks. However, if Adrienne Banks deems it unsafe to further communicate with a client, she may not send a refusal of care statement and will in turn seek legal counsel.
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Certain health conditions or injuries can be negatively affected by movement, activities, diet, supplements, or any other suggestions recommended by Adrienne Banks (Here forth- recommendations). Therefore, the client agrees to provide truthful and complete health information to the best of their knowledge and agree to keep Adrienne Banks updated on how their body is feeling throughout any session or report back any adverse reactions while participating in any recommendations. Adrienne Banks is not liable for any adverse reactions that occur by partaking in recommendations because of withheld, misleading, and/or untruthful information by the client.
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Adrienne Banks will be assessing the health of clients through all services. If a client exhibits signs or symptoms of a medical emergency, she will respond to the situation based on emergency training protocols.
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Adrienne Banks may opt out of suggesting certain recommendations or stop the session depending on the current health of the client , any contraindications, or any needs outside her scope of practice.
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For the comfort and safety of the client, if the client experiences any pain or discomfort during any of their sessions or while engaging in any recommendations by Adrienne Banks , it is the client's responsibility to cease the activity, and if needed, inform Adrienne Banks so the recommendations can be adjusted.
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Any recommendations made to the client by Adrienne Banks are specifically for that client. Adrienne Banks is not liable for any consequences for someone other than her client, who partakes in a recommendation suggested by a client of Adrienne Banks'.
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Services provided by Adrienne Banks are never sexual in nature. If the client makes sexual advances or remarks of any kind, the session may be immediately terminated without a refund.
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Sunset Moth Wellness adheres to consent laws for HIPAA and GDPR via Practice Better and Google Workspace. Learn more: Privacy and Security through Practice Better, Google Workspace Privacy and Security
If you have any questions, please email connect@sunsetmothwellness.com.
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Last updated: June 2024
HIPAA/Personal Healthcare Rights/GDPR Rights Notices
This notice describes how medical information about you may be used and disclosed by Sunset Moth Wellness (SMW) and how you can get access to this information. Please review it carefully.Sunset Moth Wellness protects your sensitive information and rights to your healthcare information in accordance with HIPAA (Health Insurance Portability and Accountability Act) standards: "The HIPAA Privacy Rule gives individuals a fundamental right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information." SMW is using only HIPAA-compliant virtual and manual tools, with signed business associate agreements when applicable, to protect all of the ways you communicate your sensitive information to us. For more information about HIPAA visit:https://www.hhs.gov/hipaa/index.html (opens in new tab or window).
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
You can:
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get an electronic or paper copy of your medical record.
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ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
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ask SMW can provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
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ask SMW to correct health information about you that you think is incorrect or incomplete.
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request changes to your health records. SMW may say “no” to your request, but will tell you why in writing within 60 days.
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ask SMW to contact you in a specific way (for example, home or office phone) or to send mail to a different address. SMW will say “yes” to all reasonable requests especially as it refers to safety.
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ask SMW not to use or share certain health information for treatment, payment, or operations. SMW is not required to agree to your request, and may say “no” if it would affect your care.
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ask SMW not to share specific information you use to pay for a service or health care item out-of-pocket with others, unless a law requires SMW to share that information.
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ask for a list of the times SMW shared your health information for six years prior to the date you ask, who SMW shared it with, and why. SMW will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked SMW not to make). SMW will provide one accounting a year, and only more for a specific legal need.
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ask for a copy of this privacy notice. You can ask for a paper copy of this notice at any time. SMW will provide you with a paper copy within 30 days.
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ask that someone make decisions on your behalf. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. If you provide SMW with this person's contact information, SMW will make a concerned effort to contact this person if appropriate, before taking any action on behalf of your health.
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file a complain directly to SMW by contacting: Adrienne Banks at connect@sunsetmothwellness.com
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file a complaint with the U.S. Department of Health and Human Services Office Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling , calling 1-877-696-6775. SMW will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:
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share information with your family, close friends, or others involved in your care after a consent form has been signed by you
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share information in a disaster relief situation
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include your information in a hospital directory
We may also share your information when needed to lessen a serious and imminent threat to health or safety. SMW will never share your information without written and expressed permission:
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If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
SMW will never share your information without written and expressed permission:
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marketing purposes
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sale of your information
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sharing of psychotherapy notes when it is not necessary to care for you in a crisis situation
Our Uses and Disclosures
Collecting your personal information is only for the following reasons:
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to treat you.
For example, evaluating your health information to develop a customize wellness plan for you.
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to use your health information and share it with other professionals who are treating you if you have signed a consent form. If and only if, SMW believes sharing your health information may save you from imminent death or serious injury or illness, SMW may share your health information without a consent form.
For example, you would like SMW to confer with other health care providers of yours.
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to use and share your health information to run the practice, improve your care, and contact you when necessary.
For example, SMW uses health information about you to manage your treatment and services.
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use and share your health information to bill and get payment from health plans or other entities with your permission.
For example, SMW gives information about you to your Health Saving Account provider so you can use it to pay for our services.
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to help with public health and safety issues.
SMW can share health information about you for certain situations such as:
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preventing the spread of a communicable disease
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helping with product recalls
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reporting adverse reactions to supplements
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reporting suspected abuse, neglect, or domestic violence
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preventing or reducing serious threat to anyone's healthy and safety
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to conduct research.
SMW may use or share your information for health research. If this occurs, you will first be contacted, for which you have the right to refuse such use. Either your health information will be de-identified ( i.e. your name or any info that would make it possible for someone to figure out who you are would not be included) or SMW will ask for your permission to use your identifying information. If you do not respond to requests for permission, SMW still has the right to use your de-identified data for analytic purposes.
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to comply with the law.
SMW will share information about you if state or federal laws require it, including with the U.S. Department of Health and Human Services.
For example:
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to ensure that SMW is complying with federal privacy law.
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respond to organ and tissue donation requests
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work with a medical examiner or funeral director
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share health information with a coroner, medical examiner, or funeral director when an individual dies
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address workers’ compensation, law enforcement, and other government requests.
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for law enforcement purposes or with a law enforcement official
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health oversight agencies for activities authorized by law
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special government functions such as military, national security, and presidential protective services
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respond to lawsuits and legal actions, court or administrative order, or in response to a subpoena.
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SMW's Responsibilities
SMW will not use or share your information other than as described here unless you given written permission.
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SMW is required by law to maintain the privacy and security of your protected health information.
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SMW will let you know promptly if a breach occurs that may have compromised the privacy or
security of your information.
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SMW must follow the duties and privacy practices described in this notice and give you a copy of it.
Sunset Moth Wellness adheres to privacy laws via the use and signed agreements between Practice Better (Better Practice Privacy and Security opens in new tab or window) and Google WorkPlace (Google Workspace Privacy and Security opens in new tab or window)
Last updated: September 2024
Mandated Reporting-All Services
Reporting Suspected Abuse to Yourself or Others:
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Healthcare providers are mandated reporters. What this means is if Adrienne Banks of Sunset Moth Wellness, who is a certified holistic health practitioner and licensed massage therapist, becomes suspicious during a client interaction, that someone is being abused, neglected, or is a danger to themselves or others, she must report this information to an appropriate authority. This particularly applies to abuse or neglect towards people under the age of 18 and over the age of 59. This may mean divulging otherwise confidential information to an appropriate third party.
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All Fifty (50) States and the District of Columbia in the United States of America have enacted laws which address mandatory reporting of child and elder abuse to protect the health and safety of these vulnerable populations.
For more information, visit https://www.childwelfare.gov/topics/systemwide/laws-policies/state/ and https://www.americanbar.org/content/dam/aba/administrative/law_aging/2020-elder-abuse- reporting-chart.pdf
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If you are a client living in another country, and Adrienne Banks suspects any form of abuse is occurring to you or anyone directly connected to you and deems it medical and ethically appropriate to report, she will research reporting laws in your region and follow those laws accordingly.
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Last updated: June 2024
Liability Waiver-Physical Activity-Wellness Support Sessions
This liability waiver applies to any movement the client may participate in that is hosted my Sunset Moth Wellness (SMW) regardless of age. If you are the guardian registering a minor (a person under the age of 18), note that the following information applies to the minor, and you are agreeing to take full responsibility for their health and safety while they participate.
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I understand that services at SMW's may include guiding me through physical movements. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all injuries and accidents to myself or others, or damages to, or loss of property, which may incur through participation. I will make sure that my place of practice is as safe as possible.
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Any information expressed by the instructor is not a substitute for medical attention, examination, diagnosis or treatment. I affirm that if there is any question about my health, a licensed physician has verified my good health and physical condition to participate in this class.
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I will make the instructor aware of any current medical conditions, pregnancies, post-natal or post-surgical information, or physical limitations by notifying SMW either through answering the health questionnaire during the registration for a class or by email (connect@sunsetmothwellness.com) as soon as I can, as needed, before each virtual class I attend.
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I understand that services provided by Adrienne Banks are never sexual in nature. If I make sexual advances or remarks of any kind, my participation in the class may be immediately terminated without a refund.
I hereby agree to release and waive any claims that I have now or may have hereafter against Sunset Moth Wellness and Adrienne Banks (practitioner). I affirm that my participation or the minor’s participation is voluntary, and at my or their own risk.
If you have a question about these terms, please wait to book your class and email connect@sunsetmothwellness.com or through your Practice Better portal with your question.
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Last updated: June 2024
Liability Waiver-Physical Activity- Customized Workshops and Group Movement Classes
This liability waiver applies to the participant of any class that is hosted my Sunset Moth Wellness (SMW) regardless of age. If you are the guardian registering a minor (a person under the age of 18), note that the following information applies to the minor, and you are agreeing to take full responsibility for their health and safety while they participate.
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I understand that SMW's virtual and in-person activities may include guiding me through physical movements. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all injuries and accidents to myself or others, or damages to, or loss of property, which may incur through participation. I will make sure that my place of practice is as safe as possible.
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Any information expressed by the instructor is not a substitute for medical attention, examination, diagnosis or treatment. I affirm that if there is any question about my health, a licensed physician has verified my good health and physical condition to participate in this class.
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I will make the instructor aware of any current medical conditions, pregnancies, post-natal or post-surgical information, or physical limitations by notifying SMW either through answering the health questionnaire during the registration process for a class or by email (connect@sunsetmothwellness.com) as soon as I can, as needed, before each virtual class I attend.
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I understand that services provided at Sunset Moth Wellness are never sexual in nature. If I make sexual advances or remarks of any kind, my participation in the class may be immediately terminated without a refund.
Last updated: June 2024
Information on Recording Virtual Services at Sunset Moth Wellness
There may be times when it would be helpful to you to have a recording of your service. For example, if Adrienne shows you a specific exercise she want you to practice, or if she explain an assignment and it would be easier for you understand and remember it if you rewatched her explanation of it. She does not automatically record sessions, and it will be at her discretion to accept a request to do so. Except in certain situations, she will not tape live private classes.
If you would like a recording or if I think it would be helpful to you to record all or part of our session, then Adrienne or you can bring that up in the session and Adrienne can begin and stop recording at any time. If you do agree to recording the session, Adrienne will ask you both before and after the start of the recording that you have consented to the recording of the session. You have the right to ask for the recording to be stopped at any time and to request that it be deleted from my files at any time.
Adrienne will be making this recording through through computer and storing it on the Sunset Moth Wellness's HIPAA compliant google drive for up to thirty (30 days). Be sure to save your recording if you would like to keep it for more than thirty (30) days. She will send it to you via your Practice Better portal or via your google drive, if you have one, or an agreed upon alternative. This will depend on file size and ease of access.
You agree to not use any of your recordings from Sunset Moth Wellness for your own promotion or post any of your recordings on any social media platforms or any other public forum without written permission from Adrienne Banks, owner of Sunset Moth Wellness.
You will not hold Sunset Moth Wellness or Adrienne Banks liable for any outcome that occurs if you share your recordings with anyone else. You understand that any recordings sent to you are specifically for your healthcare and no one else's.
In compliance with HIPAA laws, Adrienne will not share a recording that states any of your private, sensitive, or identifying information with anyone else without your consent. If the recording has no private, sensitive, or identifying information, Adrienne has the right to reuse the recording for other clients or for promotional reasons.
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Last updated: June 2024