St. Michael's Homes
262 Gerrard Street East
Toronto  Ontario  M5A 2G2


Phone: (416) 926-8267,
Fax: (647) 493-2432,
Email: info@stmichaelshomes.org
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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Which service are you hoping to access? (select all that apply)
Substance Use Treatment
Aftercare/Out-patient Substance use Support
Our Place (mental health drop-in)
Transitional Housing
Contingency Management
Please tell us who you are
Salutation:
* First Name:
Middle Name:
Last Name:
Preferred Name:
Date of Birth:
Select Date
Age:
Gender:
Please tell us how we can contact you
Preferred Language:
Please include the area code with phone number.
You can provide additional details to the phone number provided in the adjacent comments box.
Home/Main Phone:
Permission to Call?
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No
Leave a Message?
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No
Comments:
Work Phone:
Permission to Call?
Yes
No
Leave a Message?
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No
Comments:
Alternate Phone:
Permission to Call?
Yes
No
Leave a Message?
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No
Comments:
Email Address:
Address:
:
City:
Province:
Country:
Postal Code:
What is your mother tongue?
If your mother tongue is neither English nor French, in which of Canada's official languages are you most comfortable?
Additional Information (Optional)
What is your marital status?
Do you have children at home? If yes, how many?
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All information is protected under Ontario privacy legislation and is kept confidential.