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Welcome to Epilepsy Toronto
Epilepsy Toronto 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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* Indicates required question
Email
*
Your email
Your First Name
*
Your answer
Your Last Name
Your answer
Your preferred pronouns (select all that apply)
She/Her
He/Him
They/Them
Other:
Phone number
Your answer
Please select the statements that best describe your e
pilepsy or seizure affiliation:
I live with epilepsy
My child has epilepsy and/or seizures.
I have functional seizures (or PNES).
I experience seizures that are not yet diagnosed.
I have a spouse, parent or sibling who lives with epilepsy and/or seizures.
I work with someone with epilepsy and/or seizures.
I have general questions about epilepsy, seizures and/or your agency.
Other:
When is your birthdate?
*
Your answer
If you are filling this form out on behalf of your child, what is your child's birthday?
Your answer
What is your reason for reaching out to Epilepsy Toronto? (For example, recently diagnosed, looking for counselling, employment support, seizure monitor, donation, volunteer, ect.)
*
Your answer
What city do you live in?
*
Your answer
Your Postal Code
*
Your answer
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