Konektee

1. Full Name

2. Age

3. Gender

4. Contact Number

5. Email (optional)

6. Address / Current Location

7. Emergency Contact Person & Number

8. Preferred language for counselling

English

Nepali

9. Are you a:

10. Country of employment (if applicable)

11. Duration of stay abroad

12. Type of work you were involved in

13. Reason for return

14. Previous counselling or mental health support

Yes

No

15. Mental health diagnosis history (if any)

16. Current mental health medication

17. Chronic medical conditions

18. Current challenges

19. Duration of concerns

20. How are these concerns affecting your daily life?

21. Recent major loss or traumatic event

22. Feeling unsafe

Yes

No

23. Thoughts of harming self/others

Yes

No

24. Preferred type of support

25. Preferred mode of counselling

Online call

In person Visit

26. Preferred counsellor

Male

Female

No preference

27. Preferred timing (with timezone)

28. Consent to use information for services

29. Consent to be contacted

Psychosocial Counselling Intake Form

A. Basic Information

B. Migration Background

C. Psychosocial History

D. Present Concerns / Reasons for Seeking Support

E. Risk Screening (Confidential)

F. Service Preferences

G. Consent