Form 45, 47, and 49 (Community Treatment Order - CTO)

A Community Treatment Order (CTO), is a provision under the Ontario Mental Health Act that allows a physician to mandate supervised treatment on a patient when they are discharged from hospital. The overall goal of CTOs is to prevent mental health deterioration due to medication non-compliance. This is especially applicable in patients with a history of deteriorating when off medication, and show improvement when they are back on medications.

In Ontario, an active CTO allows a patient to be recalled back to hospital for assessment (through issuing a Form 47). A CTO expires every 6 months, but can be renewed. Each year, there is also a Consent and Capacity Board (CCB) hearing to justify whether a CTO needs to remain in place (to ensure that personal liberties are not infringed). CTOs are used throughout the world, and the specific criteria to be eligible for a CTOs varies between different jurisdictions.

Download CTO Forms

A Form 49 (Notice of Intention to Issue or Renew Community Treatment Order), is the initial notice given to the patient to let them know a physician intends to start or renew a CTO.

There Is Another Kind of Form 49!

There is a completely different and unrelated Form 49 (Warrant of Committal) issued through the Ontario Review Board (ORB), which is essentially a detention order. Don't confuse the two!

A Form 45 (Community Treatment Order), is the Form that issues the CTO formally, and details the conditions of the treatment order in the community.

Only a physician may issue or renew a CTO.

  1. Determine eligibility for a CTO
    • Does the patient meet at least 1 of the following criteria?
      • Patient has been a patient in a psychiatric facility on 2 or more separate occasions in the last 3 years, or
      • Patient has been a patient in a psychiatric facility for a cumulative period of 30 days or more in the last 3 years. The admission period does not include the Form 1 assessment period (i.e. - the first 72 hours of admission), or
      • Patient has been the subject of a previous Community Treatment Order
  2. Develop a Community Treatment Plan (CTP)
    • A CTP is a document of a comprehensive plan of community based treatment, care, or supervision that is less restrictive than being detained in a psychiatric hospital.
    • Involve the patient, substitute decision maker (SDM) (if applicable), the outpatient team, and anyone else (e.g. - social worker) who will be involved in the CTO to develop the CTP
  3. Notify the hospital CTO coordinator (varies by hospital)
    • The CTO Coordinator will provide the issuing physician with the CTP and Form 49
    • The CTP is a distinct treatment under the Health Care Consent Act (HCCA) and thus, the patient must be assessed specifically assessed for capacity to consent to the CTP itself. This assessment must be documented in the chart.
    • If the patient is incapable, informed consent for the CTP must be obtained from the SDM and documented.

      Don't Forget This Step!

      Regardless of whether the patient is capable or incapable for a medication treatment, you must additionally assess whether the patient is capable to consent to the CTP itself as well and this must be documented in their chart! The CTP is a unique treatment in and of itself (i.e. - just because a patient is incapable for an antipsychotic, does not mean they are necessarily incapable for a CTP (though it usually is the case)!
  4. Certifiability (Box A or Box B criteria) assessment
    • The issuing physician must assess whether the patient meets the criteria under s.33.1(4)c of the MHA and document this, that is:
      • Does the patient meet the criteria for a Form 1, Form 3, or Form 4 under either Box A or Box B criteria?
        • Is the patient suffering from a mental disorder such that he or she needs continuing care, treatment or supervision in the community?
        • If the patient does not receive care, treatment, or supervision in the community, is he/she likely to cause serious bodily harm to him/herself or another person, suffer serious physical impairment, or suffer substantial mental or physical deterioration?
  5. Signing the final Forms
    • The CTP must be signed within 72 hours of conducting the assessment in Step 5.
      • The original Form 49 and the CTP must signed by all parties must be placed on the chart.
      • One copy (each) of the Form 49 and the CTP goes to the patient, the SDM (if applicable), and CTO Coordinator (so that they can request Rights Advice for the patient/SDM)
    • Steps 4, 5, and 6 are ideally, all done at the same time.
  6. Confirmation of Rights Advice (Form 50)
    • A CTO cannot be issued until both the client (plus SDM, if applicable) have obtained rights advice (or best efforts to provide rights advice have been unsuccessful)
    • The CTO Coordinator will contact the physician when rights advice has been completed.
  7. Complete the Community Treatment Order (Form 45)
    • The physician and patient (or SDM) signs the Form 45 in order to complete the CTO.
    • The patient/SDM must sign before the physician.
    • The Form 45 is then given to the:
      • Patient or SDM (if applicable)
      • Outpatient clinic/hospital (where the care will be delivered)
      • Officer-in Charge
      • Others named in the treatment plan (e.g. the monitoring psychiatrist, case manager, etc.)
      • CTO Coordinator
  8. Complete the Notice of issuance or Renewal of Community Treatment Order (Form 46)

Order of Issuing Forms for a CTO

  1. Form 1 (Application by Physician for Psychiatric Assessment)
  2. Form 33 (Notice to Patient under Subsection 59(1) of the Act and under Clause 15(1) (a) and 15.1 (a) of Regulation 741)
  3. Form 49 (Notice of Intention to Issue or Renew a Community Treatment Order)
  4. Form 50 (Confirmation of Rights Advice)
  5. Form 45 (Community Treatment Order)
  6. Form 46 (Notice to Person of Issuance or Renewal of Community Treatment Order)

After a CTO is Issued

  • To renew a CTO: issue a Form 48 (Application to Board to Review Community Treatment Order) and Notice to Board by Physician of Need to Schedule Mandatory Review of Community Treatment Order — Section 39.1 (4)
  • To recall a patient for examination or assessment: issue a Form 47 (Order for Examination - Sections 33.3(1) and 33.4(3) of the Act)

A Form 47 (Order for Examination), can be issued by a physician when a patient is non-adherent to an agreed-upon treatment plan as laid out in the Community Treatment Order (Form 45). The patient is brought to a healthcare facility by law enforcement. This does not need to be a hospital emergency room - it can be a clinic, or any other area where a physician works. The patient is then seen for examination and the treatment is then given to the patient. The physician who receives the Form 47 when the patient is brought into hospital can give the treatment, it does not have to be the same physician who issued the Form 47.

Good Practices for Issuing a Form 47

  • You must specify the hospital/location where you want the patient should be brought (e.g. - the patient has health records there and you want them to go there)
  • When issuing a Form 47, attach the Form 45 (CTO) and Community Treatment Plan. This is important, because the Form 45 dictates the treatment plan, and the physician receiving the Form 47 needs to know what treatment is.

There are several common errors that physicians may make when assessing a patient brought in on a Form 47. Most commonly a patient brought into hospital on a Form 47 are seen in the emergency department.

Form 47 Myths and Common Errors

MD Myth/Error Explanation
“A patient on a CTO is always incapable.” Almost true. Most patients on a CTO are deemed incapable to consent. However, there are patients who are capable who also consent to a CTO as a “safety net.”
“I deem them to be not certifiable at this time.” A patient on a CTO is by definition, certifiable under Box B criteria of the Mental Health Act. Your one-time assessment of the patient at this time does not overturn the certifiability.
“I deem this patient to be capable at this time, and cannot give the CTO treatment” If the patient was previously found incapable, you cannot overturn a finding of incapacity based on your one-time assessment of the patient when they are brought in on the Form 47. If a patient was incapable when the CTO was issued (as typically is the case), they continue to be assumed incapable to consent to the treatment outlined in the CTO right now as well.
“I have not been able to reach the SDM, therefore I cannot give the CTO treatment.“ You still need to give the treatment, because there is already a treatment plan in existence as documented in the CTO. You do not need to contact the SDM as they have already given permission.
“I cannot give this person the treatment, because they are refusing it.” The patient cannot refuse treatment because a treatment plan has already been outlined in the CTO. You are legally able to enforce treatment.

A patient does not need to be incapable to be on a CTO, although the majority of patients are. Therefore, although 99% of the time, patients on a CTO are already deemed incapable, you must keep in mind there are also capable patients on CTOs. An example would be a patient with bipolar I, and episodes of mania where they decompensate rapidly. Patients like these may request the use of a CTO as as “safety net” to enforce treatment on them during a manic episode.

CTO for a Capable Patient vs. Incapable Patient

Incapable patient Capable patient
Can be brought in under a Form 47 and be obliged to accept treatment from previously dictated 6-month treatment plan (Form 45) Can be brought in on a Form 47, and be assessed for capacity and treatment, but ultimately, the patient can cancel the CTO if they want, provided they are still capable. If consent for CTO is withdrawn at any point, (even when they are well, or if the patient says: “by the way cancel that CTO” in a random phone call) you have a 72-hour period to re-assess the patient. You can actually re-issue a Form 47 to compel a patient to come to hospital for that assessment.