Lynwood Charlton Centre
526 Upper Paradise Rd
Hamilton  Ontario  L9C 5E3


Phone: (905) 389-1361,
Fax: (905) 389-8765
Self-Referral
Please tell us how we can help you
Indicate if the issue is related to Addiction, Mental Health, or Both:
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Salutation:
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You can provide additional details to the phone number provided in the adjacent comments box.
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If your mother tongue is neither English nor French, in which of Canada's official languages are you most comfortable?
Additional Information (Optional)
Do you have children at home? If yes, how many?
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Parental 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 outlined 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 writing a letter to the ASN program.
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 outlined in this form can be used for the purpose of a program or service referral. I understand that I can withdraw this consent at any time by writing a letter to the ASN program.
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