UTAH SPECIAL MASTER contact FORM

Name *

First Name

Last Name

Phone *

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By clicking this box, I understand that Special Master services are not a medical intervention, and are not covered by health insurance.

I understand that Special Master services are not covered by health insurance.

This form is not intended as a secure means of communication. Please do not include private information, including (but not limited to) personal health details and credit card numbers. By checking this box I indicate that I agree with the Privacy Policy and Terms and Conditions. *

I agree with the privacy policy, and understand that this form is not a secure form of communication.

I agree to receive SMS text messages from Kenny Levine, LCSW for scheduling purposes only. I understand that message frequency varies and data rates may apply. I understand that I may opt-out by replying "STOP" at any time. I understand that I may reply "HELP" for assistance. I understand consent is not required to purchase goods or services. Kenny Levine, LCSW does not use text messages for marketing purposes.

I agree to receive text messages for scheduling purposes.