Northern Ireland - one off counselling

"*" 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 this is not a crisis service

Your details

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*
Do you have a diagnosis of epilepsy or are you caring for someone who does? Please tick all that apply.*
What are you hoping to gain from the one off emotional support session? Please tick all that apply.*
Select your preferred time slot for a one off emotional support session.*
Would you prefer your session to be:

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