Request Assistance

Any person who has identified needs associated with their epilepsy can receive individualised services and support from Epilepsy Action Australia. All services are delivered in partnership with the person with epilepsy or the family of a child with epilepsy and may consist of information provision, case management and other services to address individual needs.

By filling in and submitting this confidential form, your request will be referred to an appropriate Service Consultant who will contact you within 24 hours to discuss how we may best assist you.

Title: *

First Name: *

Last Name: *

Date of Birth: *

Address: *

Suburb: *

State: *

Post Code: *

Phone Number:

Mobile:

Email: *

Reason For Request: *

Are you of Australian Aboriginal or Torres Strait Island Origin: *

Do you speak a language other than English at home: *

Other language/s: