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October 2022
Community Treatment Order: Qualified Health Professional
The Mental Health Act (MHA) of Alberta was amended January 1,
2010, to include Community Treatment Orders (CTOs). CTOs are
intended to support a person with serious and persistent mental
illness to remain stable in their own community. With the necessary
treatment and support, the risk of decompensation can be reduced,
potentially avoiding, or reducing the cycle of admission, discharge,
and re-admission as a formal patient.
For a CTO to be issued, a CTO “must identify the person who is
responsible for the supervision of the community treatment order and
any reporting obligations in respect of the community treatment order in accordance with the
regulations” (MHA, section 9.1(2)(f)).
The Mental Health Amendment Act, 2020, proclaimed in force on September 30, 2020, repealed
section 9.7 the designation of a physician for the purposes of supervising a CTO, to now include any
psychiatrist, physician, or nurse practitioner willing to supervise a CTO.
The issuance of a CTO usually originates from psychiatric units in designated facilities across the
province. Depending on where the person resides, they may be admitted to a psychiatric facility far
removed from their own community. Thus, it may not be practical for the issuing psychiatrist or
Qualified Health Professional (QHP) on staff at the facility to supervise the person’s CTO following
hospital discharge. Therefore, the person requires a supervising QHP who will take on this role of
supervising a CTO in the person’s own community.
Supervising a CTO
The main elements for supervising a person’s CTO are:
• monitoring/assessing a person’s mental health
• providing treatment and care
• receiving & responding to non-compliance reports; possibly issuing apprehension orders
• attending & presenting evidence at Review Panel hearings (potentially at Court of King’s
Bench)
• completing renewals of CTOs
• collaborating with the treatment team and Zone CTO Coordinator
o one of the renewal examinations must be completed by a psychiatrist completing
amendments to an existing CTO
Explanation of the CTO Process
The primary elements of CTOs are issuances, renewals, cancellations, amendments, review panel
hearings and responding to non-compliance.
Qualified Health
Professional (QHP)
Currently, a Psychiatrist,
Physician, or
Nurse Practitioner
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When a person is considered for a CTO, the CTO Zone Coordinator potentially works closely with the
treatment team and QHPs to help determine whether a CTO is appropriate. The CTO Zone
Coordinator also can assist in identifying and engaging services, liaises with QHPs and service
providers, as well as support and facilitate the CTO process.
Issuance/Renewal
For a CTO to be issued or renewed the person needs to meet the criteria set out in sections 9.1(1) &
9.3(1) of the MHA. There are six components in the process of issuing or renewing a CTO,
culminating in the completion of a Form 19 or Form 20:
• examination by the issuing QHP
• second examination by a QHP
o one of the examinations must be completed by a psychiatrist
• identifying the service providers and the type(s) of services and care that will be provided to
person
• identifying a QHP responsible for supervising a CTO
• determining whether the CTO will be issued or renewed with consent
These elements require significant preparation and coordination, much of which is facilitated
by the CTO Zone Coordinator. A CTO is in effect for up to six months after the day that it is
issued and will automatically expire unless it is renewed.
Service Provider
The supervising QHP is usually included as a service provider on the Treatment and Care section of
the CTO. This enables establishing and maintaining contact with the person on a CTO as well as the
provision of services, such as monitoring their physical health, mental health and medication needs.
While not specified in the MHA, the supervising QHP often plays a primary role in considering whether
continuing the CTO is in the best interest of the person and subsequently participating in the renewal
process, including the completion of a Form 20.
Non-compliance
Service providers on the CTO must report any failure to comply with treatment and/or care listed to
the CTO Zone Coordinator within 24 hours of the non-compliance (Form 27). The CTO Regulations
section 6(3) specify that the QHP supervising the CTO is to receive copies of the non-compliance
forms within 24 hours.
After reporting non-compliance, the person must be provided with reasonable assistance by the QHP
to comply with the CTO. Reasonable efforts must be made to inform the person, and if applicable,
their alternate decision maker, the person has: failed to comply, an order may be issued for them to
be apprehended and taken to a designated facility for examination, and, as a result, they may be
admitted to a facility and detained as a formal patient.
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A QHP may then issue an apprehension order if they are satisfied these efforts have occurred (MHA,
sections 9.6(1) and (2)).
Review Panels/ Court of King’s Bench
Review panel hearings occur when a CTO is renewed for the second time and at the time of every
second renewal after that until the CTO expires or is cancelled, these hearings are called “deemed
applications.” As well, the person subject to a CTO or others on their behalf may apply to the Review
Panel hearing at any time for cancellation of their CTO.
When an application for a hearing is made to the review panel or Court of King’s Bench, the QHP who
issued, amended or renewed the CTO as well as the supervising QHP will be notified of the hearing
(MHA, section 40(1)(c)). The onus is on the QHP who issued, amended or renewed the CTO, or the
person supervising the CTO, to demonstrate the person subject to the CTO continues to meet criteria
as noted in the MHA 9.1(1) (a) to (e), (MHA, section 42(2)). However, usually the supervising QHP
attends these hearings and presents information and evidence of how the person meets criteria for
the CTO.
Amendment
Section 9.4 of the MHA states that a CTO may be amended by a QHP. To amend a CTO, the QHP
would complete a Form 21. A CTO may be amended for various reasons, including when a person
moves or there are changes to their treatment.
Cancellation
Section 9.5 of the MHA states that a CTO may be cancelled at any time by a psychiatrist “if any of the
criteria set out in section 9.1(1)(b) to (d) cease to apply.” The psychiatrist would complete a Form 22
noting any treatment recommendations.
Recommended Resources/Information
• Mental Health Act
• Mental Health Act Forms
• CTO Regulation
• CTO Information Sheet
• Alberta Mental Health Patient Advocate
• Government of Alberta: Alberta Health Care Insurance Plan (AHCIP) CTO Billing Information
• CTO Zone Coordinator Contact List
The Mental Health Act forms and links to these resources are available on the Alberta Health Services
Mental Health Act external webpage.
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Mental Health Act Qualified Health Professional Roles
MHA Forms
Psychiatrist
Physician
Nurse Practitioner
Form 19 & 20
CTO Issuance & Renewal
• At least one of the examinations must be completed by a psychiatrist
Form 21
CTO Amendment
Form 22
CTO Cancellation or Expiry
• For the cancellation of a CTO, only a psychiatrist can complete this form
• For the expiry of a CTO, a QHP can complete the form
Form 23
CTO Apprehension Order
Form 24
CTO Examination on
Apprehension
• At least one of the examinations must be completed by a psychiatrist
