Cook Counseling & Therapy | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

I confirm that I live in Wisconsin or will be physically located in Wisconsin when receiving counseling services.

Client Preferences

What appointment times generally work best for you?

Morning Afternoon Evening Weekend

Preferred clinician

Select a clinician from the list

How would you prefer to meet with your therapist?

In-person at our Green Bay office Telehealth A combination of in-person and telehealth I'm not sure yet

Is there anything else you would like us to know?

You're welcome to share anything that would help us better understand what you're looking for or what is important to you.

Limited to 600 characters

Billing & Payment

Cook Counseling & Therapy is a private-pay practice that does not bill health insurance directly. Payment is due at the time of service. We can provide documentation that you may submit to your insurance company for possible out-of-network reimbursement. Reimbursement is not guaranteed and depends on your individual plan.

I understand that I am responsible for my counseling services.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.