Student counselling request form

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Email *

Counseling sessions

You can choose to have your counseling sessions physically or virtually.

Student information

First Name *

Email *

Mobile phone no. *

Reg No. *

Campus *

Main Campus, Ruaraka

Town Campus

Kitengela Campus

Western Campus, Kisumu

Questions about ( please check all that apply) *

Private matter

Relationship issue

Am stressed

I have a diagnosed mental illness

I feel sad

Self awareness

Am anxious

Am having suicidal thoughts

Family issue

Other:

Required

Preferred mode of session *

Virtual

Face to Face

Other:

Required

Please write the available time you would like to be contacted/ see a counselor Monday -Friday 9am-5pm *

Time windows are not a guaranteed appointment, however your selection helps us target the most likely time when you will be able to take the call

Please note we will respond to your request in 1-2 working days depending on the volume of requests received

Confidentiality

Please note while counseling sessions are confidential we can not ensure confidentiality of information given online due to the nature of the Internet and email technology.

I have read and understood the confidentiality statement *

Agree

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