Inquiry Form

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Inquiry Form

Please complete this form for the individual seeking therapy.

After completing this form, Nikki Pagano, LCSW will reach out to you to schedule a 15 minute phone call to discuss more about what you would like help with and what Nikki can offer.

First Name *

Last Name *

Address (incl city, state and zip code) *

Phone number *

Email *

Date of birth *

YYYY

Gender *

Female

Male

Non-binary

Prefer not to say

Pronouns

School (if applicable)

Custody Status (if a child, click all that apply)

Single parent household

Dual parent household

Parents married

Parents never married

Parents separated

Parents divorced

Joint / shared legal custody

One parent with sole legal custody

One parent deceased

Other legal guardian

Other:

Type of treatment *

Individual therapy

Family-based treatment / Maudsley method

Parenting support

Evaluation / second opinion

Professional Consultation / supervision for providers

Please briefly describe what you are looking for help with. *

Your first and last name (if different than the individual seeking therapy)

Your relationship to the individual seeking therapy (if applicable)

Your phone number (if different than the individual seeking therapy)

Your email (if different than the individual seeking therapy)

How did you hear about Nikki Pagano, LCSW?

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