EMHware :: Lynwood Charlton Centre

Lynwood Charlton Centre

526 Upper Paradise Rd

Hamilton Ontario L9C 5E3

Phone: (905) 389-1361,
Fax: (905) 389-8765

Referral Type:

New Referral

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Referral:

ASN Child Youth Referral ID

Date:

2025-12-17 03:15

Status:

Draft

Attachment(s):

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Attachment Type:

Referral Information:

	Referral Source
	Reason(s) for the referral 500 character max

Child/Youth Information

First Name

Last Name

DOB

Age

Years Months

Gender

Gender Identity

Does the client identy as LGBTQ+?

Preferred Pronoun

Child/ Youth Address Information

Address Line 1

City

Location/County

LHIN

Postal Code

Province

Country

Child's Preferred Language

Who should be contacted for this referral?

	Relationship
	Parent / Caregiver Information
	Contact Name
	Preferred Language
	Address Line 1
	City
	Postal Code
	Province
	Country
	Contact Information
	Phone (Home/Main)
	Permission to call? Phone (Home/Main)
	Permission to leave a message? Phone (Home/Main)
	Email
	Permission to contact via Email

Additional Referral Information

Please select all that apply:

There is an immediate risk of harm (actively engaging in self-harm and/or expressing suicidal ideation).

There has been a recent discharge (within 30days), from the hospital (Emergency or Inpatient Unit) due to self-harm/suicidal ideation/ mental health concerns).

There is a risk of losing home and/or school placement due to mental health concerns.

Consent

Parent/Caregiver consent
	I agree that by submitting this form I give my consent for the ASN program to contact me for further information. I agree that the information outlines in this form can be used for the purpose of a program or service referral for my child. I understand that I can withdraw this consent at any time by contacting Lynwood Charlton Centre.
Child's Consent
	I agree that by submitting this form I give my consent for the ASN program to contact me for further information. I agree that the information outlines in this form can be used for the purpose of a program or service referral for my child. I understand that I can withdraw this consent at any time by contacting Lynwood Charlton Centre.
	By sending this form, I allow Lynwood Charlton Centre to contact me. All information is protected under Ontario privacy legislation and is kept confidential.