Initial Appointment Request Form         Cooke Counseling and Consultation LLC

UPDATE 2023 : To request, reschedule, or cancel an appointment please call me at 616.259.4796, or call CCWM at 616-805-3660, or text our support staff at 616-209-8198 for immediate assistance.

Please tell them you are looking to see Dan Cooke.  If I do not have any availability you can ask them to email me directly to figure out a first appointment time.

Email : support@counselingcenterwm.org

Fax : 616-805-3631 **Please write Attention Dan Cooke on cover page**


Congratulations on taking the step to pursue counseling. I acknowledge that this can be a difficult journey and I want to do everything I can to help you move in the direction of your goals. By completing information in this form, you are providing me with the necessary information to guide your counseling journey. I appreciate you taking the time to complete this information and look forward to working with you.

If you are experiencing a mental health emergency please contact 911 or go to your local emergency room.  We are not currently able to respond to mental health emergencies through our website.  After this form is complete our staff will follow up within two business days.  

- Dan Cooke LMSW CAADC
Cooke Counseling and Consultation LLC
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Client Name (First and Last) *
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