All information given will be treated with the utmost confidentiality, and
complete discretion will be exercised when contacting you.

Please note that the DSGA is based, and convenes, in London only.

Name: __________________________________________________________

Address: ________________________________________________________

_________________________________________________________________

Postcode: _______________________ Telephone: _____________________

Occupation: _______________________ Age: _________________________


I am interested in: (please tick)

The Support Groups

The Shyness and Social Anxiety Programme

The Low Self-Esteem Programme

The Personal Relationship Programme

Individual Therapy


I have been/am in therapy: (please give details)

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

I have had experience relevant to convener training:
(please state qualifications)

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

If you do not have access to a printer phone 020 7328 8391 leaving your
details on our answer phone and we will send a form to you.

DSGA, 37b New Cavendish Street, London W1G 8JR