Mental Health Service Screening Form
For Ethiopian and Eritrean Zega queer community members referred for therapy
About this form
House of Guramayle is partnering with Galck Kenya to connect Ethiopian and Eritrean Zega queer community members with affirming mental health support. This form helps us understand who you are and the kind of support you are looking for, so we can match you with the right therapist.Your information is confidential and will only be shared with the Galck Kenya clinical team for the purpose of arranging therapy. Please answer only the questions you feel safe answering. Items marked * are required.
About You
Full name or chosen name (How you would like us to call you)
*
Age
*
Country of origin
*
Ethiopia
Eritrea
Other
Country of origin - Other (specify)
Current location in Kenya, Ethiopia or Eritrea
Preferred way for us to reach you (tick all that apply)
Phone call
WhatsApp
Signal
Telegram
Email
Other
Phone (with country code)
Please enter a valid phone number.
Format: (000) 000-000000.
Email or messaging handle
Is it safe for us to leave a message?
Yes
No
Only with a code word
Your Identity
Share only what feels safe and right for you. You can skip any question.
How do you identify under the LGBTIQA+ umbrella? (tick all that apply)
Lesbian
Gay
Bisexual
Transgender
Intersex
Queer
Asexual
Non-binary
Gender non-conforming
Questioning
Other
Your pronouns (tick all that apply)
*
she/her
he/him
they/them
ze/zir
any pronouns
other
Gender (optional)
Are you currently out about your identity?
Not out to anyone
Out to some people
Out to most people
Out publicly
Prefer not to say
Support Needs and Urgency
Areas you would like support with (tick all that apply)
Anxiety or stress
Depression or low mood
Trauma or PTSD
Family or rejection
Identity exploration
Relationships
Community or isolation
Substance use
Physical health concerns
Housing or safety
Legal or documentation issues
Economic/work stress
Other
Briefly describe what you are going through and the kind of help you would like (Share as much or as little as you feel comfortable with.)
*
How urgent is your need?
*
Immediate—I am in crisis
Urgent—within a week
Moderate—within a month
Not urgent
Have you received therapy or counselling before?
Yes, I am currently in therapy
Yes, in the past
No, this would be my first time
Prefer not to say
Preferred language for therapy
Amharic
Tigrinya
Oromo
English
Swahili
Other
Preferred format of sessions
In person
Online video
Phone only
Text/chat
No preference
Therapist preferences (e.g. gender, age, lived experience)
Anything else our team should know? (safety concerns, accessibility needs, things to avoid, etc.)
Safety, Emergency Contact, and Consent
These questions help us know if you need urgent support today. They are not used to judge you.
In the last two weeks, have you had thoughts of harming yourself or ending your life?
*
No
Sometimes
Often
Right now
Prefer not to say
Are you currently in a safe place to live?
*
Yes
Somewhat
No
Prefer not to say
Is there a trusted person we can contact in an emergency?(only if you want to share)
*
Emergency contact relationship
*
Emergency contact phone number
*
Please enter a valid phone number.
Format: (000) 000-000000.
Consent and understanding
*
I consent to House of Guramayle sharing the information in this form with Galck Kenya for the purpose of arranging therapy services.
I understand that my information will be kept confidential and stored securely.
I understand that I can withdraw my consent at any time by contacting House of Guramayle.
I understand this form is not therapy itself and that a Galck Kenya counsellor will follow up with me to begin the process.
Signature of the client
*
Date (client)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff-Only Intake and Referral Tracking
Signature of intake worker (House Of Guramayle)
Date (intake worker)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FOR STAFF USE ONLY
Screening Notes
Risk level
*
Low
Moderate
High
Crisis
Referred to (therapist/team)
Date referral sent to Galck Kenya
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Follow-up arranged
Submit
Submit
Should be Empty: