Contact Form

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

If you require immediate or urgent 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, Rachel Samson will review this information to determine her suitability to provide services to you via the online clinic. This decision is based upon Rachel'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 Rachel 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.

Psychology/Consulting

If you were referred by another health professional, please provide details below.

If you have previously engaged in psychology services/coaching, what was your experience like?

Was it beneficial? Was it unhelpful? Did you achieve your goals? What did you like about it?

Why are you interested in accessing psychology/consulting with Rachel Samson? Why do you think our service might be the right fit for you?

What are your current therapy/coaching goals?

It is helpful if you can be specific here, your answers will help us determine whether this service is the right fit for you.

Have you recieved a mental health diagnosis?

Yes

Im a mental health professional seeking consultancy

If yes, please provide details

e.g., depression, anxiety, PTSD, BPD

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

Do you identify as /have you been formally assessed as gifted and/or neurodivergent?

Yes, Gifted

Yes, Autistic

Yes, Highly Sensitive / Sensory Processing Sensitivity

Yes, Other

Prefer not to specify

Your Details

First name

Family name

Email address

Phone number

Age

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

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

Please tick any of the following statements that apply Samson & Bullus is an online clinic that provides telehealth consultations

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 access to 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 sessions

Data

I understand that by submitting this data I agree to the Samson & Bulluss Psychology/Consulting terms and conditions and the privacy policy displayed on the Samson & Bulluss Psychology/Consulting website.

Your information will be encrypted.

Contact Form

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

Psychology/Consulting

Your Details

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

Rachel Samson

Clinical Psychologist, M.Psych (Clin)