Intake Form – Epilepsy Resources & Support at Local Epilepsy Association of WNY

Epilepsy Association of WNY Intake Form

Complete this intake form so our team can better understand your needs and determine eligibility for our programs and services. Once submitted, a member of our team will follow up with next steps.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Your Full Name*

Date of Birth*

Phone Number*

Email*

Preferred Contact Method

Your Address*

City*

State*

Zip Code*

What service are you interested in?*

Are you currently receiving services through the Office for People With Developmental Disabilities (OPWDD)?*

Yes

How can we help you?*

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Get Started with Support

We’re happy to have you here and can assist with any questions you may have. Please don’t hesitate to reach out.

info@epilepsywny.org

339 Elmwood Avenue, Buffalo, NY 14222

Main Office:
(716) 883-5396

Southern Tier Contact:
716-498-4396