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Email
Telephone
Self Referral Form
Thank you for reaching out to the Epilepsy Association of Calgary. Filling in this form is the first step in accessing programs and services from the Epilepsy Association of Calgary and helps our counsellor/ educators provide the right information.
Preferred Name
Date of Birth
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Preferred Pronouns
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He/Him
She/Her
They/Them
Location
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BC
Northern AB
Out of Country
Out of Province
SK
Southern AB
Can We Add You To Our Newsletter
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No
Yes
How Did You Find Us
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An EAC Event
Community / Health Org
Community Neurologist
Community Pediatric Clinic
Emergency Department
Family Member
Family Physician
Foothills Epilepsy Clinic
Other
Seizure Monitoring Unit
Self-Referral
South Health Campus Epilepsy Clinic
Epilepsy
How Are You Impacted By Epilepsy
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Community Professional
Employer
Family Member Has Epilepsy
I am an Epilepsy Professional
I Have Been Diagnosed With Epilepsy
I Have Been Diagnosed With PNES
I Have Both Epilepsy and PNES
I Have Experienced Seizures But Not Yet Diagnosed
My Child Has Been Diagnosed With Epilepsy
My Partner Has Been Diagnosed With Epilepsy
Other (please explain)
If Other, Please Explain
If You Are Diagnosed With Epilepsy, Are You Living With Other Conditions (Check All That Apply)
Anxiety
ADHD
Depression
Developmental Delay
Genetic Condition
Learning Challenges
Respiratory
Other (Please explain)
If Other Condition Please Explain
Services
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
Thank you! One of our counsellor/educators will be in touch with you shortly!
Preferred Name
Date of Birth
Preferred Pronouns
Location
Can We Add You To Our Newsletter
How Did You Find Us
Epilepsy
How Are You Impacted By Epilepsy
If Other, Please Explain
If You Are Diagnosed With Epilepsy, Are You Living With Other Conditions (Check All That Apply)
If Other Condition Please Explain
Services
Which Services Would You Like More Information About (Check All That Apply)
If Other, Please List
Thank you! One of our counsellor/educators will be in touch with you shortly!
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