Gulf Coast Epilepsy Alliance

New Members, Referrals & Annual Renewal Form

Welcome Friends!

* Date:

* Is this submission for a New Member, a Referral, or an Annual Renewal?

* Do you have epilepsy, seizures, or a brain disorder?

* My connection to epilepsy is:

* Name of person with epilepsy or seizure/brain disorder?

* First Name

* Last Name

Address

City

State

* Postal Code

* Phone

* Email

* What is the best way to contact the member or referred person?

Gender

Birthday

* Are you seeing a Neurologist or an Epileptologist? (Please list your Doctor's first name, last name, and contact information.)

An epileptologist is a neurologist who specializes in the diagnosis, treatment, and management of epilepsy, also known as seizure disorder , in people of all ages. Epileptologists have additional training and education in diagnosing and managing various kinds of seizures. They can also help manage the social and emotional aspects of epilepsy.

Please list diagnosis and medications:

* Are you using a seizure rescue medication? If so, what type and name of medication?

Nayzilam (midazolam) and Valtoco (diazepam) are nasal sprays that are approved by the FDA to treat seizure clusters in adults and children. Nayzilam is for patients 12 and older, while Valtoco is for patients 6 and older. These medicines are considered rescue therapies, but are not approved for daily use.

* Do you need assistance with Social Security Benefits / SSI / assistance with state applications?

* Are you aware of S.U.D.E.P, seizure alerting or prediction devices, and related technologies that are designed to enhance safety for a person with epilepsy?

SUDEP stands for Sudden Unexpected Death in Epilepsy. According to the National Institutes of Health, SUDEP is the most common epilepsy-related cause of death. A discussion with your doctor to determine where you or your loved one fall on the risk spectrum is very important.

* Are you aware of the Texas Compassionate-Use Act and Sam's Law? (Hyperlinks are available on our homepage.)

In 2015, Texas passed the Compassionate-Use Act, which allowed the first legal use of low-THC cannabis products in the state for patients with intractable epilepsy. It was expanded in 2019 and 2021 to include other conditions.

Sam's Law (HB 684), was signed into law on June 11, 2019 with Governor Greg Abbott, two GCEA Representatives and many Texas Epilepsy Advocates. The law requires all Texas ISD public school personnel whose duties include regular contact with students to be trained in seizure recognition and seizure first aid.

How may we help you? Please note, GCEA meets online every 2nd Thursday, monthly, to answer all your questions and medical concerns. See you there!

Additional information you would like to share:

* Would you like to volunteer with GCEA?

* May we highlight your story on social media? Personal stories help us raise awareness and advocate for our cause. Please provide your full name below to give us consent: [Full Name]

* May we use your photo for marketing on our social media? Photos help us raise awareness and advocate for our cause. Please provide your full name below to give us consent: [Full Name]

Reminder: Annual Membership is $25.00. Click on the SUBMIT button below and you will be redirected to make your payment at gceaTX.org/ways-to-give.

Through generosity of foundations, corporations and individuals, GCEA is making a real difference in the lives of those touched by epilepsy, seizures and brain disorders across the Coastal Counties of Texas.

GCEA is a 501(c)(3) charitable organization, all contributions are tax deductible. Your generous donation will fund Gulf Coast Epilepsy Alliance's mission. EIN# 84-2099498

Thank You For Your Support!

Est. 2019

Gulf Coast Epilepsy Alliance (GCEA) is a 501(c)(3) nonprofit organization dedicated to providing essential services and support to individuals affected by epilepsy, seizures, and other brain disorders in the Gulf Coast region of Texas.

Did you know?

1-in-10 will have a seizure in his or her lifetime

and 1-in-26 will be diagnosed with epilepsy. [cdc.gov]

Through generosity of foundations, corporations and individuals, GCEA is making a real difference in the lives of those touched by epilepsy, seizures and brain disorders across the Coastal Counties of Texas.

GCEA is a 501(c)(3) charitable organization, all contributions are tax deductible. Your generous donation will fund Gulf Coast Epilepsy Alliance's mission.

EIN# 84-2099498