1 About you
Full name *
Age * Choose… Under 18 18 – 24 25 – 35 36 or older Welcome! A parent or guardian will also need to sign the consent form.
Email address * We send your confirmation and consent form here.
Phone / WhatsApp *
2 Your session
Type of session * Choose… Individual counselling Group therapy GBV support Family / couple session
What would you like support with? Not sure yet / prefer to say in person Depression Anxiety Gender-Based Violence Grief & Loss Self-Esteem School & Work Stress Substance Use Relationships
Preferred date * We are closed on that day. Please choose another date.
Preferred time * Choose… Morning (9am – 12pm) Afternoon (12pm – 3pm) Late afternoon (3pm – 6pm)
Anything you’d like us to know? (optional)
This form is not for emergencies. If you are in danger right now, call 999 or 112, or the Kenya Red Cross toll-free line 1199.
