Expression of Interest Form

Register your interest in psychology/consulting services with Erin Bulluss, PhD

Please correct the errors described below.

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.

Your Details

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

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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.
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.
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.

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