Emergency Financial Assistance
Epilepsy can create a range of challenges for individuals and families that can result in short-term financial hardships. Epilepsy Foundation New England offers resources to help members in our epilepsy community in times of need, bringing financial assistance to people living with epilepsy with an emphasis on helping people maintain their health, safety, and quality of life.
Current Year Funding Program ID
Update the default text for this field annually with the ID of the Funding Program to be default on incoming requests.
Anyone with a confirmed diagnosis of epilepsy and a demonstration of need who resides in MA, ME, NH, RI or VT is eligible for Emergency Financial Assistance for Clients. Which state do you live in?
*
Please Select
MA
ME
NH
RI
VT
Who is filling out Application?
Person Living with Epilepsy
Parent/ Caretaker
Parent/Caretaker Name
First Name
Last Name
Who Has Epilepsy?
*
First Name
Last Name
Applying Contact Name (First and Last Name)
Application Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
EFNE Request Name
EFNE Financial Assistance
EFNE Request Name
E-Mail
example@example.com
Mobile Number
Format: (000) 000-0000.
Person living with Epilepsy Email
example@example.com
Person living with Epilepsy Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Household Information
Household Member Names and ages
*
Primary Epilepsy Connection
*
I Have Epilepsy
Date of Birth (PWE)
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Diagnosis (PWE)
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Doctor Last Name
Doctor First Name
Doctor Name
Doctor First Name
Doctor Last Name
I do not know my Doctor's Name.
Unknown
Doctor Unknown
True
Hospital Associated with
Please Select
Baystate Medical Center
Beth Israel Deaconess Medical Center (BIDMC)
Boston Children's Hospital (BCH)
Boston Medical Center (BMC)
Brigham and Women's Hospital
Dartmouth Hitchcock Medical Center (DHMC)
Harvard Vanguard Medical Associates Cambridge
Hasbro Children's Hospital
Lahey Clinic
Maine Medical Center
Massachusetts General Hospital (MGH)
Memorial Hospital -Maine Health
Newton - Wellesley Hospital
North Shore Medical Center
Northern Light Eastern Maine Medical Center
Rhode Island Hospital
Tufts Medical Center
UMass Memorial Medical Center
University of Vermont Medical Center (UVM)
Warrick Hospital
Wentworth-Douglass Hospital
Other
Please enter hospital if not listed in question before
How is the family member with epilepsy impacted?
*
Household Income
*
Please Select
$0-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$124,999
$125,000-$149,999
$150,000-$174,999
$175,000-$199,999
$200,000 & Up
Financial Assistance
Requested Amount
*
EFNE limits $1,000 per household annually.
Types of Assistance Requested
Please Select
Child Care / Home Care
Educational (K-12)
Housing-Rent or Mortgage
Medical
Medications
Misc.
Seizure Detection Device
Transportation
Utilities
Why Do You Need Assistance?
*
Bills Behind On
Car/Transportation
Credit Cards
Heating/Oil
Housing
Insurance
Medical Bills
Student Loans
Utility Bills
Assistance Receiving
CHIP
Fuel Assistance or LIHEAP
General Assistance
Housing Assistance
Medicaid
Medicare through your state
Snap or Food Stamps
SSDI
SSI
TANF
Unemployment
WIC
Assistance Applied for:
CHIP
Fuel Assistance or LIHEAP
General Assistance
Housing Assistance - Section 8
Medicaid
Medicare through your state
Other Snap or Food Stamps
SSDI
SSI
TANF
Unemployment
WIC
Status
Please Select
Active
Inactive
Please verify that you are human
*
Submit Application
Should be Empty: