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


Phone: (905) 389-1361,
Fax: (905) 389-8765
Referral Type:
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Referral:
Community Professional Referral Form ID
Date: 2025-06-02 14:01
Status: Draft
Attachment(s):
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Referral Form

Thank you for submitting your referral request to Lynwood Charlton Centre.

NOTE: Most referrals are processed within 1-2 business days. Should you have any questions regarding this referral, please contact our administrative team (905) 389-1361
 
Hide/ShowClient/Patient Information
 
Salutation
First Name
Middle Name
Last Name
Alias/Last Name at Birth
  
Age Years Months
DOB
Select Date Clear Date
Gender
 
Address Line 1
City
Location/County
LHIN
Postal Code
Province
Country
Preferred Language
 
Phone (Home/Main)
Comments
Phone (Home/Main)
Permission to call?
Phone (Home/Main)
Permission to leave a message?
Phone (Home/Main)
Phone (Work)
Comments
Phone (Work)
Permission to call?
Phone (Work)
Permission to leave a message?
Phone (Work)
Phone (Alt)
Comments
Phone (Alt)
Permission to call?
Phone (Alt)
Permission to leave a message?
Phone (Alt)
Email
Permission to contact via Email
 
School Board
Previous ASQ - 3/SE Completed (for ages 0-5 years)
Yes
No
Hide/ShowParent Information

You must enter a phone number or an email address where you can be reached.

Relationship to Child/Youth
 
Parent/Caregiver Name
Preferred Language
 
Same as Child/Youth
If not - please indicate below.
 
Email
Permission to contact via Email
Main Phone
Comments
Main Phone
Permission to call?
Main Phone
Permission to leave a message?
Main Phone
Phone (Work)
Comments
Alternate Phone
Permission to call?
Alternate Phone
Permission to leave a message?
Alternate Phone
Phone (Alt)
Comments
Other Alternate Phone
Permission to call?
Other Alternate Phone
Permission to leave a message?
Other Alternate Phone
Hide/ShowReferring Agency/Primary Care Information
Agency/Source Name
Agency/Referral Source
Contact Name
If differs from the Agency/Source Name.
Phone
Fax
Email
Website
Address
City
Province
Country
Hide/ShowReferral Information
Reason(s) for the Referral
Presenting Issues
Hide/ShowRisk Factors
 
Harm to Self
Harm to Others
Unable to Care for Self
Financially Vulnerable
Serious Medical Conditions/Chronic Illness
Substance Use
Other Risk Factors
Risk Factor Details
 
Date of Intake
Select Date Clear Date
 
 
I confirm that the personal health information collected, used or disclosed was received for the purpose of providing health care or assisting in the provision of health care to the individual to whom it relates. I confirm that I have obtained consent from the parent/caregiver of the child/youth, or the child/youth directly and they are in agreement to being contacted as outlined in the information provided.
 
 
I have obtained informed consent from the client/patient and/or the parent/caregiver to DISCLOSE/OBTAIN personal health information of the child or youth specific to this referral so that the professional may receive updates related to the referral.
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