Befriending enquiry form

We also accept referrals from family members, community workers and GPs. Please register their interest by providing their contact details if you have their consent and they are happy to use the service.

Without their consent we are unable to process this application so please ensure you obtain consent before completing the rest of the form

Your details

First name*

Last name*

Your email*

Phone*

How did you hear about this service?

Is there anything else you want to tell us?

Details of the person you are referring

Their first name*

Last name

Their email (if you have it)

Phone*

Is there anything else you want to tell us about the person you are referring?

How did you hear about this service?

How do you know the person you are referring?

Untitled

What is your name?*

Organisation/company*

Email*

Phone number*

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:

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

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:

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

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Your details

Details of the person you are referring

Keep in touch

Keep in touch