Information Services Evaluation Form

First Name

Last Name

Phone

Zip Code

What is your relationship to epilepsy?

I have epilepsy/seizuresMy child has epilepsy/seizuresMy parent has epilepsy/seizuresMy spouse or partner has epilepsy/seizuresAnother family member has epilepsy/seizuresA friend/co-worker has epilepsy/seizuresI work with people who have epilepsy/seizuresOther/prefer not to respond

Information Services Evaluation

Date of Contact:

Type of Contact:

	Agree	Somewhat Agree	Neutral	Somewhat Disagree	Disagree
I learned information that will help me manage life with epilepsy.
I learned about resources that will help me manage life with epilepsy.
My knowledge of epilepsy and seizures increased.
If needed, I will seek information or support from the Epilepsy Foundation of Minnesota again.
I felt comfortable asking questions and sharing personal information.
I was provided the information and/or resources I needed.

Additional thoughts/comments:

How did you hear about Information Services?

Please specify:

Contact Information

Connect Groups

Connect Groups are an easy way to meet people affected by epilepsy and share experiences in a safe and supportive environment. The structure and intent of Connect Groups vary by location to meet the needs of that community.

More Information