Family Support & Empowerment Program (FSEP) Form

Referral from a Professional
I agree that the information I provide above for myself or my child may be used by the Child Neurology Foundation and their Peer Support Specialists solely for my participation in the CNF’s Family Support and Empowerment Program (FSEP), which provides peer support and helpful resources for the journey of disease diagnosis, treatment, and management. I may revoke this consent by contacting CNF at programs@childneurologyfoundation.org. *