• ACON’s ENQUIRY FORM

    ACON’s ENQUIRY FORM

  • We offer a range of  support services for people 18 yrs and older, who live in NSW and are LGBTQ+ and/or people living with HIV and their families, including:

    • Counselling
    • Care coordination
    • Peer work support
    • Group support options

    We deliver service in person and/or via telehealth across NSW and at our Sydney, Newcastle and Lismore offices, there are no Medicare requirements.

    If you’re under 18 - contact Twenty10.

    Once you have submitted this form, our intake officer will reach out to you (or the person you referred) within 1-5 business days to book a time to complete intake.

     

  • Data collection and privacy

    We collect your personal and health information to provide you with safe and effective care. Your information is kept private and secure in line with legal and ethical requirements.

    For more details, please read ACON Privacy Policy & Website Disclaimer.

  • Are you enquiring:*
  • Has the person consented to this referral?*

  • We are unable to contact someone without their consent, please gain consent before submitting this form

  • Do you require support filling out this form?*

  • Please provide the details below and our intake officer will be in contact within 5 business days.

  • Your contact details

  • Contact details

  • Format: 0000-000-000.

  • Contact details for the person you are referring

  • This does not need to be your legal name, can be any preferred name.

  • Date of birth*
     - -
  • Format: 0000 000 000.
  • Which ACON office are they closest to?*
  • Which ACON office are you closest to?*
  • Preferred contact method*
  • Do we have consent to*
  • Has the person consented to:*
  • What’s most important to you right now?*
  • What’s most important for the person right now?*

  • If you need help while you’re waiting for us, try:

    QLife (3pm-9pm): 1800 184 527

    YARN: 13 92 76

    Lifeline: 13 11 14

    Suicide call back service: 1300 659 467

    NSW mental health line: 1800 011 511

    Beyond blue: 1300 22 4636

    Find a safe haven: Safe Haven Finder

  • If you need help while you’re waiting for us, try:

    Full Stop Australia rainbow line: https://fullstop.org.au/ 1800 497 212 (Phone and online counsellors)

    (24/7) Domestic Violence line: https://www.facs.nsw.gov.au/domestic-violence/helpline

    (24/7) Men’s line: 1300 78 99 78 Phone and Online Counselling | MensLine Australia

    Women’s Domestic Violence Court Advocacy Services: all NSW 9-5 Mon to Fri 1800 928 277 can support female only victims

    Find a Service – https://sayitoutloud.org.au/abusive-relationships/find-a-service/?state=all

  • Gender and sexuality

  • What is your sex assigned at birth?*
  • What is the person's sex assigned at birth?*
  • Were you born with a variation of sex characteristics?*
  • Was the person born with a variation of sex characteristics?*

  • (Sometimes called intersex  or differences of sex development. We ask this so we can provide the best support to you. If it’s something you think is important for us to know, it can help us tailor support for you and if you’d like, connect you with intersex community-led peer support services)

  • Cultural identity and faith

  • Do you require an interpreter to engage in services?*
  • Does the person require an interpreter to engage in services?*
  • Do you identify with a religious/faith/spiritual community?
  • Does the person identify with a religious/faith/spiritual community?

  • Please click submit

  • Should be Empty: