Assertive Community Treatment Team (ACTT)

Thresholds Homes and Supports has one of the two ACT Teams that provide services in Waterloo Region. The Assertive Community Treatment Team (ACTT) is an interdisciplinary team that provides comprehensive, community-based psychiatric treatment, rehabilitation, and support for people who experience serious and persistent mental diagnoses or concurrent issues that are complex and impair a client’s ability to function within the community and, as a result, would likely face prolonged incarceration and/or hospitalization without ACTT level supports. The team is composed of members with specialties from across the mental health field including psychiatry, nursing, social work, occupational therapy, substance use treatment, housing support, and peer support.


This is a person-centered, recovery-oriented program that helps people achieve their goals, improve their health and quality of life, and live as independently as possible. The ACT Team provides direct intensive case management and medication supports to the most vulnerable clients within the community, through a harm reduction approach within the community regardless of their housing status. This often takes the form of daily visits to a client’s home, shelter or encampment to provide medication supports such as direct observation and intermuscular injections. Support is provided through direct one-to-one supports through an assigned primary caseworker that is matched at intake with the client based on their stated goals and services needs. Ultimately the goal of the ACT team is to increase a client’s reintegration into the larger community by regularly attending social activities with team members and peers, while decreasing their involvement with emergency medical services and the judicial system.


Eligibility Criteria

  • Clients with diagnosed severe and persistent mental illnesses that seriously impair their functioning in community living

    • Priority is given to people with schizophrenia other psychotic disorders, and bipolar disorder

    • Clients with other psychiatric illnesses are eligible depending on the level of the long-term disability

    • Individuals with a primary diagnosis such as a substance abuse disorder, developmental disability and organic disorders are not the intended client group

  • 18 years and older

  • Must live in the Region of Waterloo or County of Wellington or have a plan to move to either area




  • Clients with significant functional impairments as demonstrated by at least one of the following conditions:

    • Inability to consistently perform the range of activities of daily living required for basic adult functioning in the community (e.g., caring for personal business affairs; obtaining medical, legal, and housing services; recognizing and avoiding common dangers or hazards to self and possessions; meeting nutritional needs; maintaining personal hygiene) or persistent or recurrent difficulty performing daily living tasks except with significant support or assistance from others such as friends, family, or relatives.

    • Inability to maintain consistent employment at a self-sustaining level or inability to consistently carry out the homemaker role (e.g., household meal preparation, washing clothes, budgeting, or child-care tasks and responsibilities).

    • Inability to consistently maintain a safe living situation (e.g., repeated evictions or loss of housing).




  • Clients with one or more of the following indicators of continuous high service needs:

    • High use of Schedule 1 hospital services or specialty hospital services, tertiary level services, or psychiatric emergency services such as mental health crisis response services.

    • Persistent or very recurrent severe major symptoms (e.g., affective, psychotic, suicidal)

    • Coexisting substance abuse disorder of greater than six months.

    • Involvement with the criminal justice system due to mental illness, assessed at low to moderate risk in the community, and the ACT team has determined that it is able to manage the current level of risk in the community.

    • Inability to consistently meet basic survival needs, residing in substandard housing, homeless, or at imminent risk of becoming homeless.

    • Residing in an in-patient or supervised community residence, but clinically assessed as being able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not available.

    • Difficulty effectively utilizing traditional office-based out-patient services.


Referral Process

Referrals for this program follow a centralized intake process - to make a referrals to this program you can call 1-844-HERE247 (1-844-437-3247)


You can also access the referral package at this link.