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Email
Telephone
Professional Referral For EAC Services
Protecting personal health information of patients is important to us. We have ensured that the software used to collect patient data is secure, HIPAA compliant, and follows best practices to ensure the privacy of your patients.
Date of Birth*
*
The client may require an interpreter
Is the patient under 18 or have a legal guardian
-
No
Yes
If yes, Parent or Guardian Name
Parent/Guardian Phone Number
Parent/Guardian Email (if different from above)
Referring Professional's Information
Name of Referring Professional*
*
Title of Referring Professional*
*
Phone Number of Referring Professional*
Email of Referring Professional
Organization/Clinic of Referring Professional
With consent, would you like EAC to follow up with you regarding the Patient
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No
Yes
Epilepsy Information
Year of Epilepsy Onset
Type of Epilepsy
Cause If Known
Services
PACES "group secessions for newly diagnosed patience; introductory information ", UPLIFT "group sessions cover depression and anxiety", HOBSCOTCH "One on one sessions working on memory and cognition".
Which Services Would You Like More Information About (Check All That Apply)
PACES
UPLIFT
Short Term Counselling
HOBSCOTCH
Webinars
Support Groups
Camp Fireworks
Peer 2 Peer Program
Volunteering
Other
If Other, Please List
Additional Information
Please provide any additional information you feel may be relevant or helpful
Thank you for your referral! We look forward to supporting your work through our community programs and services.
Date of Birth*
The client may require an interpreter
Is the patient under 18 or have a legal guardian
If yes, Parent or Guardian Name
Parent/Guardian Phone Number
Parent/Guardian Email (if different from above)
Referring Professional's Information
Name of Referring Professional*
Title of Referring Professional*
Phone Number of Referring Professional*
Email of Referring Professional
Organization/Clinic of Referring Professional
With consent, would you like EAC to follow up with you regarding the Patient
Epilepsy Information
Year of Epilepsy Onset
Type of Epilepsy
Cause If Known
Services
Which Services Would You Like More Information About (Check All That Apply)
If Other, Please List
Additional Information
Please provide any additional information you feel may be relevant or helpful
Thank you for your referral! We look forward to supporting your work through our community programs and services.
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