Quick Exit
Queerspace is not a crisis response service. For crisis responses phone:
  • 000 Victoria Police for immediate safety
  • 1800 RESPECT family violence and sexual assault 24-hour telephone support
  • 1800 015 188 Safe Steps Victoria available 24 hours for crisis support for women
To leave this site quickly, click the quick exit button.


If you would like to access counselling, please express interest using the form below.

If you are in crisis and in need of urgent support, please call Lifeline on 13 11 14.

Please note: Please note this form is NOT for referrers. If you are wanting to make a referral for a client, please call (03) 9663 6733. We do not provide the following services: Psychiatrists (can’t provide referrals), Legal Advice (we will refer you to Family Law Courts or Legal Aid), Mediation, Diagnostic assessments & Court Reports. Only provide your email if you consent to us emailing you. You WILL receive an auto receipt to this email address when you complete this form.

Please allow up to seven business days for our Intake team to get back to you for an Intake session, and note that we do have waiting lists for services.


    First Name



    Other Gender

    Date of Birth


    Where I currently live – my address



    Residential Address is same as Postal Address

    Postal address




    Work/Home Phone


    Do you consent for us to contact you? If yes, please tick your preferred contact method (note: you can tick more than one).

    MobileHome or WorkPhoneSMS & Voice mailEmail

    What is your country of birth

    If you were born outside Australia, what year did you arrive in Australia?

    What is your cultural background or ancestry?

    Do you identify as an Aboriginal or a Torres Strait Islander?

    Do any of your immediate family identify as Aboriginal or Torres Strait Islander origin?


    What is the main language you speak at home?

    Will you need an interpreter?


    How well do you speak English?


    Other Sexuality

    How would you rate your reading and writing (literacy) skills?

    Main source of Income

    Other Source of Income

    What is the highest education level you have achieved?

    What is your annual income?

    Do you hold a valid Health Care Card?YesNo

    What is your Health Care Card number?

    What is the main reason you are contacting us?

    I declare that the information I have provided is mine and I give consent for the team at drummond street services to contact me

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