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 fill out 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 us to get back to you and note that we do have waiting lists for services.

Title
First Name
Surname
Gender

Other Gender
Date of Birth
Pronouns
Where I currently live – my address
Suburb
Postcode
Residential Address is same as Postal Address
Postal address
Suburb
Postcode
Mobile
Work/Home Phone
Email
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?

YesNo

What is the main language you speak at home?

Will you need an interpreter?

YesNo

How well do you speak English?
Sexuality

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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