Request Services

Please fill out this form to begin the intake process. A member of our team will reach out within 1–2 business days.

About the Person Seeking Services

If you are a parent, guardian, or provider filling this out on someone else's behalf, enter the client's information here.

Client Name *

Legal Name (if different)

Date of Birth *

Contact Person

Same as client — I am requesting services for myself

Your Name *

Your Phone *

Your Email *

Your Address (optional)

Referral Information

Referring Person / Agency (name, agency, phone) *

How did you hear about us? *

Have you or the client previously received services at CSWN? *

No Yes

Is this client already working with any CSWN staff member?

Presenting Concerns

Primary reasons for seeking services *

Previous mental health treatment or hospitalization *

Service Preferences

Session format preference *

Video (telehealth) In-person Either

Any preference for a specific therapist or therapist characteristics?

Insurance & Financial

Does the client have insurance? *

No / Self-pay Yes

Approximate household income *

People in household *

What is affordable per session (out of pocket)? *

Open to working with an intern therapist (supervised)? *

No Yes

Open to an intern temporarily until a licensed provider is available? *

No Yes

Availability

Days and times generally available for appointments *

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Thank you

We've received your request. A portal invitation is on its way to the email address you provided — you can complete the rest of your intake securely through that invite.

A member of our team will also reach out within 1–2 business days to support you through next steps.

Questions? Call or text 518-545-4691.

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Already on file

It looks like we already have a request on file for you. A member of our team will be in touch within 1–2 business days. If you need to update anything or have questions, call or text 518-545-4691.