Schools have been identified as important settings for promoting adolescent mental health and well-being. Little is known about counselling practices in Ghanaian senior high schools (SHSs). This study explored counselling practices in 11 SHSs in Ghana's capital, Accra. We used convenience sampling methods to select 15 school counsellors and interviewed them about access to and utilisation of counselling in SHSs. We also explored common presenting concerns and service challenges. Data were analysed thematically and showed that most of the counsellors had a master's or doctoral degree in guidance and counselling. According to our participants, students access counselling to address school (academic and career), home (e.g. parents' problems and livelihood issues) and peer relations concerns. Other students access counselling for emotional (including suicidal ideations and self-harm), drug use and conduct issues. Counsellors provide academic advice, career guidance, financial and emotional support. Findings revealed that counsellors are facing several challenges including role conflict, work overload, deficient resources, as well as negative perceptions of counselling. Findings have implications for the government, policy makers, SHS administrators, school psychologists and counsellors and students.