Flexible Assertive Community Treatment Team (FACTT)

Thresholds Homes and Supports has one of two FACT Teams that provide services in Waterloo Region. FACTT is a multidisciplinary team compromised of social work, housing support, substance use treatment, occupational therapy, nursing and psychiatry. The mandate of FACTT is to support individuals living in the community who live with moderate to severe and persistent mental health diagnoses, such as schizophrenia and bipolar.


FACTT supports are for individuals that are mostly able to navigate their activities of daily living and medications on their own but still require the support of the team to ensure ongoing stability. This usually takes the form of weekly visits to ensure medication compliance, as well as intermuscular injections. FACTT workers are matched with clients based on their stated goals and presenting needs.


In addition to providing medication supports, FACTT provides long term case management to their clients to support them to live successfully in the community. Example of supports are managing medical appointments, connecting with local services/partner agencies, registering for community based programs including psychosocial educational programming, residential substance use treatment resources and recreation by providing individualized one-to-one support on a weekly to monthly basis based on the individual client’s needs. The FACT Team is able to adapt the intensity of support based on individual needs.


Eligibility Criteria

  • 18 years or older

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

  • Must have a diagnosed or diagnosable severe and persistent mental illness

  • Must meet criteria for Psychiatric Condition Requiring Care and Treatment and Functional Difficulties (listed below)

    • Functional difficulties are the consequence of psychopathology and not transient in character (i.e. systemic/long term, not less than 6 months)

  • Person requires a Coordinated Care/Assertive Team based approach


Psychiatric Condition requiring care and treatment

  • Persons with a diagnosed or diagnosable severe and persistent mental illness (SPMI) that requires a coordinated team service model


Functional Difficulties

  • Psychosocial/environmental problems including ability to maintain stable housing,  difficulty with activities of daily living

  • Severe limitations in social and community functioning (involvement with criminal justice services or community policing, social isolation)

  • Significant history of hospitalization or emergency room visits


Priority Status

  1. Returning client after being assessed to require rapid engagement to intensive team based services.

  2. Clients requiring a Community Treatment Order (CTO) and treatment team but not requiring ACTT level of care ongoing

  3. Critical Time Intervention principles: discharge from hospital and still requiring intensive supports to maintain stabilization of symptoms

  4. Risk related to harm to self or others

  5. Community concern including frequent presentations to emergency and community policing or criminal justice involvement, risk of homelessness

  6. Stable clients being discharged from ACTT teams who still require intensive services to continue to improve in their recovery

  7. Transitional Aged Youth (18-30), who are not eligible for Early Psychosis Services

  8. Chronological order on waitlist (community based)


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.