Counselling enquiry form

Complete the form below if you are interested in our Northern Ireland counselling service

"*" indicates required fields

The information you provide will only be used for the purpose of accessing the counselling service.

We will not keep this information after you have accessed the service. We will only use your contact details if you complete the ‘keep in touch’ section at the back of the form.

Criteria for accessing the counselling service

  • You are over 18 years of age
  • You consent to engage with online or telephone counselling services
  • You have a diagnosis of epilepsy, or you are caring for someone with a diagnosis of epilepsy
  • You live in Northern Ireland

    • Please note that this is not a crisis service

Your details

Do you have a diagnosis of epilepsy or are you caring for someone who does? Please tick all that apply.*
Which counselling support service are you interested in?*
Date of birth*
Please select the day, month and year of your birth.
Name*
Can we send you a text?*
Can we leave you a message?*
Address*
What are you hoping to gain from counselling and/or the group sessions? Please tick all that apply.*

Keep in touch

We’d love to keep in touch with you about our latest news and campaigns, and how you can support our life-changing work. Please select yes below so you can hear from us:
Email
Phone
Text
From time to time, we may contact you by post unless you tell us otherwise.
Epilepsy Action will never swap, share or sell your details. For more information, read our privacy policy. You can update your preferences at any time by contacting our supporter care team on 0113 210 8800 or emailing supportercare@epilepsy.org.uk

More support from Epilepsy Action

Epilepsy Action Northern Ireland Campaigning for better services in Northern Ireland The Epilepsy Action helpline Talk and support – virtual groups Talk and support – local groups Latest news Epilepsy stories About epilepsy Living with epilepsy
Epilepsy Action Northern Ireland Campaigning for better services in Northern Ireland The Epilepsy Action helpline Talk and support – virtual groups Talk and support – local groups Latest news Epilepsy stories About epilepsy Living with epilepsy

Here to support you

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Call the Epilepsy Action helpline

If you would like to talk to someone about epilepsy, our trained advisers are here to help.

0808 800 5050
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Send us your question

Send a question to our trained epilepsy advisers. (We aim to reply within two working days).

Contact us today