Self Referral Form

Agency Referral please complete all parts on this form.

If you are referring yourself, please complete Part 2 & 3.

Confidentiality & Data Protection: Sharon De Smit Counselling & Psychotherapy is registered with the Information Commissioner’s Office (ICO), Registration Number: ZB677789 and any information that is kept is subject to the Data Protection Act 2018 (DPA 18) and the United Kingdom General Data Protection Regulation UK-GDPR