Epilepsy South Central Ontario
Epilepsy South Central Ontario offers support services to people living with epilepsy, other seizure disorders, their family members, those who care for them and work with them.

This intake form will help us identify who best to address your needs, from within our organization or beyond.
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Email *
What city do you live in?
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Your Postal Code
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Phone number
Your First Name *
Your Last Name
Person with Epilepsy's Date of Birth
 *
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If completing this form on behalf of a Person with Epilepsy, what is your Date of Birth?

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Your preferred pronouns (select all that apply)
What is Your Preferred Method of Communication? *

Have you ever received support from another epilepsy agency in Ontario?

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If yes to the above, which agency?
Please select the statements that best describe your epilepsy or seizure affiliation:
What is your reason for reaching out to Epilepsy South Central Ontario? (For example, recently diagnosed,  looking for counselling, employment support, seizure monitor, donation, volunteer, etc.)
 *
How did you hear abour our Epilepsy Agency?
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