Application for Referral to a Lawyer

Please provide us with a brief description of the facts of your case, including, if appropriate, contact information for your attorney. The description should indicate: The specific type of discrimination or other illegal act(s) that you believe occurred, including how it was related to epilepsy; The identity and location of any employer, school or other entity responsible for the act(s); The date(s) on which the act(s) occurred; Whether you have filed a complaint with a court or a state or federal agency (if so, identity the court or agency and the status of the complaint); and For employment matters, whether the employer is a federal or state agency and whether you are a union member. Also describe the type of seizures you experience, how frequently they occur, and the effect of the seizures (and anti-seizure medication you take) on your daily activities such as sleeping, mental concentration and the ability to work. Please note that by submitting this information you are authorizing the Epilepsy Foundation, the Jeanne A. Carpenter Epilepsy Legal Defense Fund and its affiliated organizations and staff to disclose the necessary information to third party attorneys for the limited purpose of case review and selection, and understand that such disclosures will be kept confidential and protected by the attorney-client privilege in accordance with established ethics rules in your state.