Fill-out referral form for the CTT Program you feel is most appropriate for your participant
Upload all required paperwork at the end of the referral form * If you are unable to upload the forms please email them to the program you are referring to: ACT: cttACTadmissions@pmhcc.org
CTT will review the referral and provide a conditional authorization
Submit a program discharge summary / letter to the program you are referring to
Complete closure in Webfocus
CTT will send out acceptance form and admission date
*** n.b CTT Case Management Programs are voluntary. All referrals must be accompanied with a participant signature. You may download the signature form here. The signature form is used in those instances where the participant was unable to sign the original referral.
Review Medical Necessity Criteria.
Fill-out referral form for the CTT Program you feel is most appropriate for your participant.
Upload all required paperwork at the end of the referral form. * If you are unable to upload the forms please email them to the program you are referring to: ACT: cttACTadmissions@pmhcc.org
CTT will review the referral and provide a conditional authorization.
Submit a program discharge summary / letter to the program you are referring to.
Complete closure in Webfocus.
CTT will send out acceptance forms with an admission date.
Please review the Medical Necessity Criteria below for Assertive Community Treatment prior to completing the application.
Participants referred to CTT ACT Program(s) must meet the eligibility requirements for Assertive Community Treatment Services, which includes:
* If the applicant is unavailable to sign the electronic referral, please print out this form and have them sign the CTT Application for Services Signature Form. Upload the completed signature form in the attachments section of the online application. You can also email additional attachments to email@example.com if needed.
* CTT Case Management Programs are voluntary. All referrals must be accompanied with a participant signature.
Diagnosis: Primary diagnosis of schizophrenia or other psychotic disorders such as schizoaffective disorder, or bipolar disorder as defined in the DSM 5. Individuals with a primary diagnosis of a substance use disorder, intellectual disability or traumatic brain injury or are not the intended group.
Significant functional impairments including:
Inability to consistently perform the range of practical daily living tasks required for basic adult functioning in the community (i.e., maintain personal hygiene, meet nutritional needs, care for personal business affairs, obtain medical, legal and housing services, recognize and avoid common dangers or hazards to self and possessions, or persistent or recurrent failure to perform daily living tasks except with significant support or assistance from others such as friends, family or relatives.
Inability to be consistently employed at a self-sustaining level, or inability to consistently carry out homemaker roles (i.e., household meal preparation, washing clothes, budgeting or child-care tasks and responsibilities).
Inability to maintain a safe living situation (i.e., repeated evictions or loss of housing)
Functioning level: Global Assessment of Functioning Scale (as specified in DSM IV-R or revisions thereafter) rating of 40 or below.
Meet at least two of the following criteria which are also indicators of impairment:
At least two psychiatric hospitalizations in the past 12 months or lengths of stay totaling over 30 days in the past 12 months that can include admissions to psychiatric emergency services.
Intractable (i.e., persistent or very recurrent) severe major symptoms (e.g., affective, psychotic, suicidal).
Co-occurring mental illness and substance use disorders with more than six months duration at the time of contact.
High risk or recent history of criminal justice involvement which may include frequent contact with law enforcement personnel, incarcerations, parole or probation.
Literally homeless, imminent risk of being homeless, or residing in unsafe housing.
Reside in an inpatient or supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or require a residential or institutional placement if more intensive services are not available,
Have difficulty effectively utilizing traditional case management or office-based outpatient services, or evidence that they require a more assertive and frequent non-office based service to meet their clinical needs.
Adults age 18 years or older.
A person shall be considered to have a serious and persistent mental illness when all of the following criteria for diagnosis, treatment history, and functioning level are met: