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Testimonials
Thank you for a wonderful inservice program today. The Norwalk school nurses could not speak more highly of your presentation. We all learned so much... Grace - School Nurse Supervisor



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This unique program links people living with epilepsy together so they can provide and gain support, knowledge, share their experiences, talk and listen, while furthering their understanding of epilepsy.

First name:
Last name:
Phone Number:
Address:
City, State, Zipcode:
Email:
Best Way to Contact: Phone E-mail
Languages Spoken: English
Spanish
Other:
Date of Birth or Current Age:
When Were You Diagnosed?:
I am Available to Speak With Others About: Seizures
Tonic Clonic Absence Complex Partial
Simple Partial Other:

Surgery
Type:

Medication
Type:

Vagus Nerve Stimulator

Pregnancy / Women Issues

Young Adult Issues

Senior Issues

Employment

Driving

Spouse / Family

Other
I would like a list of telephone numbers of other people who have epilepsy: Yes No
I would like my name included on a list for other people to call or email: Yes No
Please tell us more about your yourself. Include anything not listed above or specific concerns you might have.
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