IN CRISIS? CONTACT THE CRISIS RESPONSE SERVICES 24/7 AT 1-866-888-8988

District Act Referral Form

ASSERTIVE COMMUNITY TREATMENT (ACT) Referral Screening Tool

The ACT model is based on a recovery-oriented, long-term community based intensive case management service with specific eligibility and admission criteria. It is important to note that referrals to ACT services should not be made with the expectation that the referral will facilitate an early discharge from an inpatient hospital admission. Other community supports should be considered in discharge planning until ACT services are able to admit clients considered appropriate for ACT services.
Exclusions – These clients would not be considered appropriate for ACT services: 1. Primary diagnosis of personality disorder, substance abuse, developmental disability, or organic disorders (all more appropriately treated by other specialized services). 2. Client is too violent or has other significant risks that would impact safe community care. 3. Client is in long term care/nursing home or Homes for Special Care.
Your Name:
Invalid Input

Intake Criteria (* indicates required criterion)
Aged 18 +*
Invalid Input

Confirm The Following:
Invalid Input

Axis I diagnosis *

Confirm The Following:
Invalid Input

The applicant is willing to participate in the frequency and intensity of ACTT services*

Heavy system use: *

Invalid Input

Hospital admissions (more than 50 days in past 2 years preferred) Increased use of medical/support services x 6 months (family doctor, emergency department, outpatient psychiatry, crisis services) Has not been successful in less intensive conventional mental health community services (including case management)

Intensive community support required: *

Invalid Input

Needs intensive support (i.e. ACT) in order to:Move from long term inpatient or supervised setting to the community, or, Avoid a long term institutional or residential placement if already in the community, or, Prevent long term institutional or residential placement because currently living with family and family supports are faltering or insufficient to meet the client’s needs.

One or more of the following: *

Invalid Input

Poor medication adherence and/or treatment resistant Severe persistent functional impairment, such as:Inability to consistently perform the range of practical daily living tasks required for basic adult functioning in the community (e.g. personal care, meal planning/cooking, homemaking tasks, budgeting, attending appointments)Difficulty with employment/vocational issues or carrying out the homemaker role (e.g. child care tasks)

Housing problems:
Invalid Input

Inability to maintain a safe living situation (e.g. homelessness, at risk of homelessness, multiple evictions, difficult to house)Needs supportive housing Able to live in more independent housing if intensive support is available

Additional factors:
Confirm The Following:
Invalid Input

Addictions: Co-existing substance abuse disorder x 6 months or longer

Note: In the event that there are conflicting opinions between the ACT Team and the referring source with respect to a primary diagnosis and primacy of symptom presentation, the ACT Team shall exercise due diligence in gathering information from all available sources and the ACT Team’s determination of the diagnosis at time of referral shall be viewed as definitive and shall determine acceptance or refusal of the referral.
reCAPTCHA(*)
Invalid Input

Submit

Contact Information

To find additional contact information and directions to find us please click here.

1 (807) 468-1838
227 Second Street South
Kenora, Ontario
P9N-1G1
This email address is being protected from spambots. You need JavaScript enabled to view it.
Designed by Nufuzion Design
Copyright 2018 - CMHA | Kenora Branch