Heath Care Provider Form: Lorna Myers PNES Scholarship

Your patient is applying for a Lorna Myers PNES Scholarship.  This form must be completed by 11:59pm ET on April 30, 2025.

Through this scholarship program, Epilepsy Alliance America seeks to recognized the personal achievements of those impacted by Psychogenic Non-Epileptic Seizures (PNES) / Functional Seizures.  The scholarship provides tuition assistance to be used at a United States based center of higher learning (trade school, university, college) in pursuit of certification, associates, bachelors, masters degree, etc.

It is a requirement that the applicant submit proof of a PNES / FS diagnosis.  Please submit the form below.

If you have any questions you can reach out to Epilepsy Alliance America directly at [email protected].

Health Care Provider Form

    First Name (Required)

    Last Name (Required)

    Street Address (Required)

    City (Required)

    State (Required)

    Zip (Required)

    Email (Required)

    Applicant Name (Required)

    Does the patient have a diagnosis of PNES / Functional Seizures?
    YesNo

    How long have you been treating the applicant?

    Please share any information about the applicant that you think would be beneficial for the review committee as they review the Scholarship Application.

    Attachments - This is optional. If your recommendation is already written and available as a PDF, you can attach it here. (.pdf, .docx, .txt)