Epilepsy Reach Mental Health Services Referral Form

Thank you for reaching out to Epilepsy Reach. We are committed to connecting individuals affected by epilepsy with professional mental health services that meet their needs. Please complete the form below, and a member of our team will provide you with referrals to mental health professionals in our directory.

Name *

Select your age range: *

Phone *

Email *

Preferred Contact Method *

State *

Do you prefer in-person or virtual services? *

Other

Are you looking for a therapist with experience in: *

Other

Have you been diagnosed with epilepsy? *

If so, when?

Do you have health insurance? *

Insurance Provider (if applicable):

If you do not have insurance, are you open to sliding-scale or low-cost therapy options?

Is there anything else you would like us to know about your needs or preferences?

If sliding-scale there

Signature *

Clear Signature

By submitting this form, you agree to allow Epilepsy Reach to provide you with mental health referrals based on the information provided. Your information will remain confidential and will not be shared outside of our referral process.

Epilepsy Reach Mental Health Services Referral Form

Follow Us!

Follow Us!