Expression of Interest Form

Please note: submitting this form does not guarantee eligibility for our services

If you require immediate support, please contact your local mental health crisis service or helpline

Thank you for your interest in Samson & Bulluss Psychology/Consulting. Please complete this form as best you can (required fields are marked with a red asterisk) then press submit to send with the security of HIPAA compliant encryption.

Please be aware that submitting this form does not guarantee eligibility for our services. Once you have submitted the form, Erin Bulluss will review this information to determine her suitability to provide services to you via the online clinic. This decision is based upon Erin's availability at the time of your expression of interest, her strengths and experience, your location, as well as the logistics and limitations of an online therapy space. This decision is not a reflection of you, your value, your worth, or your need for support. Please allow up to 3 weeks between submitting the form and receiving contact from our admin team.

Please note, Samson & Bulluss Psychology/Consulting is not a crisis service; there may be some time between reaching out and receiving a response. We may also have a waiting list for services. As such, if you require immediate support, please consider reaching out to your local crisis service, helpline, or see your General Practitioner for referral options. If your life is currently in danger, call 000 (if you are in Australia) or go to your local emergency department to seek urgent medical attention.

Please be aware that Erin is only able to offer psychology services (including therapy) to people residing within Australia. She is able to offer consultancy services to people outside of Australia, which tend to be educational rather than therapeutic in nature.

Erin primarily works with older adolescents and adults who are on the autism spectrum, while also providing support to mental health professionals who work with Autistic clients. Do you identify as Autistic?

Yes, I self-identify as Autistic

Yes, I am formally diagnosed

I am not sure

I don't, but I am a professional seeking to learn more about working with Autistic people

I don't, but I have a loved one who is Autistic

No, I don't

Please indicate below which of these options best describes your situation

I would like 1-2 sessions of personal or professional consultancy around autism

Please note, this option includes psychoeducation or professional development only, and does not include assessment or therapy. Erin is unable to offer ongoing services following the 1-2 sessions.

I would like to be placed on the waiting list for future psychology/mentoring sessions

Please note, the current waiting period for services is over 18 months

I have seen Erin for psychology services before and I would like to reengage

Why are you interested in accessing psychology/consulting services with Erin? What do you hope to gain from the sessions?

Have you accessed any other psychology/mental health services before? If so, please describe your experiences with particular focus on what you found helpful (if anything) and what you found unhelpful (if anything).

Have you ever been hospitalised for mental health reasons?

Yes

Yes, not in the last 2 years

I am a mental health professional seeking consultancy

Are you comfortable with online sessions via a secure video chat platform?

Yes

I'm not sure

Please tick any of the following statements that apply

I have a laptop, PC, tablet, or other device with a camera, microphone, and speakers

I have access to steady, fast internet connection

I have a quiet, comfortable, private space that I can use for online sessions

I have a safe living environment that allows me to feel comfortable accessing online therapy

Is there anything else you feel is important to include in this expression of interest?

Your Details

Please provide the details of the person seeking to access psychology/consulting services

Full name

Age (years)

Where are you located? (Please provide state/province and country)

An automated email confirming successful form submission will be sent to this email address shortly after you have pressed the submit button. Please check your spam folder if it does not appear in your inbox.

Email is my preferred contact method

Phone number

Phone is my preferred contact method

Nominated contact person (full name and relationship to you)

Please complete this section if you would prefer that our admin team contact someone else on your behalf, such as a parent, partner, or support worker. By completing this field you are giving consent for us to contact this person on your behalf. Please leave blank if this does not apply.

Nominated contact person (email)

Nominated contact person (phone number)

Your information will be encrypted.

Expression of Interest Form

Please note: submitting this form does not guarantee eligibility for our services

Your Details

Please note: submitting this form does not guarantee eligibility for our services

Dr Erin Bulluss

Clinical Psychologist