01 Formtestpage - Epilepsy Smart Australia

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Professional Referral Form

To refer your patient / client to our National Epilepsy Support Service for important information, resources and access to their local, state-based epilepsy service provider for ongoing, comprehensive support, please complete the form below. This will be sent directly to the National Epilepsy Support Service for prompt follow-up with the client.

⚠ Please flag any urgency in your referral — waiting times may apply during busy periods.

1 CLIENT DETAILS (Person with Epilepsy being referred)

First Name

Last Name

Date of birth

Is this a new Diagnosis? (<12 Months)

Mobile Phone

Postcode

Is Interpreter Required

If Yes, what language?

2 PARENT / GUARDIAN DETAILS (if applicable)

First name

Last name

Mobile Phone

Postcode

Relationship to client?

3 REFERRING PROFESSIONAL'S DETAILS

First Name

Last Name

Company Name

Position

Postcode

Phone Number

4 SUPPORT SERVICES REQUIRED

5 CLIENT CONSENT

I have obtained the client's consent / provided consent (Guardian)

To share their personal information with Epilepsy Smart Australia

For Epilepsy Smart Australia to contact them directly using the contact information provided

Looking for support? Call the National Epilepsy Support Service on 1300 761 487 Monday - Friday