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Mental Health and Addictions Service

Community Outreach Services

The St. Michael’s Mental Health and Addictions Community Outreach Services provide interprofessional team-based care to adults experiencing mental health and concurrent disorder difficulties. We support people along a spectrum of illness severity, with the goals of supporting recovery and quality of life in the community. The services offered are:


The FOCUS Team is a partnership program between St. Michael’s Hospital Mental Health and Addictions Service and Cota. 

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FOCUS teamThe program relies on an interdisciplinary team to provide a continuum of integrated intensive case management (ICM) and Assertive Community Treatment (ACT) services to meet both the immediate and future intensity of services required by the client. Services are organized to allow for flexibility of movement between levels of services – ICM and ACT - while maintaining continuity of care. A wide range of evidence-based treatments are offered including Cognitive Behavioral Social Skills Training (CBSST), Cognitive Adaptation Training (CAT), Illness Management and Recovery (IMR), Dialectical Behavior Therapy (DBT), Cognitive Behavior Therapy (CBT) and trauma counselling. Focus consists of a multidisciplinary team including psychiatrists, mental health nurses, psychologists, vocational and occupational therapists, social workers, mental health case managers, addictions specialists, rehabilitation therapists, peer support specialists and personal support workers.

Services offered

The Focus Team operates seven days per week with on-call available support 24 hours per day. Services provided by the team are individualized for each client.  Clients may receive group and/or individual psychotherapy, support with medications, crisis prevention and intervention support, medication monitoring and management, symptom monitoring and management, psychoeducation, skill teaching, support around physical health needs, substance use issues, finances, housing or shelter, access to basic needs such as food and clothing, activities of daily living, educational issues, work or meaningful activity, legal issues, social activities, family issues, and support networks.   

Eligibility criteria

Individuals who are experiencing current serious mental health problems that significantly impair their ability to function and live well within the community are eligible for services. Typically, challenges with functioning would be demonstrated by at least one of the following:  Significant challenges in being able to consistently perform the range of activities of daily living required for successful personal functioning in the community (e.g., caring for personal affairs; obtaining medical, legal, and housing services; recognizing and avoiding common dangers or hazards, meeting nutritional needs; maintaining personal hygiene; maintaining employment or carrying out the homemaker role).

  1. Are 18 – 65 years old.
  2. Are not currently served by an assertive community treatment (ACT) team.
  3. Are residing in the Mid-East Toronto Health Link (METHL), or, are using acute care services at St. Michael’s Hospital and living within the St. Michael's catchment area. And
  4. Have experienced two or more psychiatric hospitalizations in the past two years or recurrent use of the ED (more than five visits in the past 12 months) for mental health problems. And
  5. Exhibit two or more of the following:
    1. Significant challenges in being able to consistently maintain a safe living situation (e.g., repeated evictions or loss of housing).
    2. An acute and/or chronic medical illness which requires intensive support (e.g. chronically bedridden, homebound, terminal illness, severe mobility limitations, unstable medical condition) and difficulty effectively utilizing traditional office-based out-patient services.
    3. A coexisting substance use disorder of greater than 6 months duration.
    4. Criminal justice involvement in the context of mental health and addictions problems in the past year. And
  6. Have been assessed as being able to be safely supported by the FOCUS team, within the limitations of the resources available. Please note that the FOCUS team is not able to safely support individuals who have been assessed as requiring an admission to a medically monitored/supervised institutional or residential setting.

How to access the service

Referrals are through The Access Point. Please submit application on line at  or call The Access Point at 416-640-1934 to obtain an application form. Once the application form is submitted, The Access Point will assess the client for eligibility; if the client meets the eligibility criteria, The Access Point will send the referral to the FOCUS Team.

Community Connections Case Management Program

The Community Connections Case Management program is an intensive case management (ICM) program.

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Community Connection Case Management ProgramThe program serves adults in southeast Toronto, who may have a serious mental illness, homelessness and concurrent substance use issues and who require treatment and recovery support in the community.

The St. Michael's community connections team consists of a psychiatrist and case managers from various disciplinary backgrounds, including occupational therapy, social work and nursing.

Services offered

The team provides outreach, treatment, rehabilitation and recovery support, in clients' homes or elsewhere in the community. Case management services are available Monday to Friday, 9 a.m. to 5 p.m.

Eligibility criteria

Adults 18 years old and over who have a serious mental illness with or without a concurrent substance use disorder living in the Community Mental Health Service catchment area.

How to access the service

To access St. Michael’s Mental Health Ambulatory and Community Mental Health Programs a patient referral form must be completed and faxed to 416-864-5007. For further information please call 416-864-3095.

Starting Treatment Early for Psychosis Service (STEPS) to Youth Program

The Starting Treatment Early for Psychosis Service (STEPS) for Youth program is designed to provide early intervention services for youth experiencing signs and symptoms of a first episode of psychosis. We work with youth between the ages of 14 to 35. Our clients may also be homeless and have problems with drugs or alcohol.

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STEPS for Youth Program teamServices offered

Assessment, treatment and case management services are provided by an interdisciplinary team including: psychiatry, nursing, occupational therapy and social work. The team provides outreach services to meet clients in their homes or in the community. Clients receive weekly support from the team. Services are provided for up to three years. Clients are supported to connect with the appropriate service before they are discharged from the program.

STEPS uses a recovery-oriented approach to provide:

  • assessment
  • treatment
  • help and support with school, work and social activities
  • family education and support
  • public education and advocacy
  • linkages to community agencies and services
  • weekly group programming

Eligibility criteria

  • Youth age 14-35 experiencing signs and symptoms of what may be early psychosis.
  • Clients must be living in our catchment area: Yonge St. to Victoria Park, Bloor/Danforth to Lake Ontario.

How to access the service

The Access Point will accept applications, screen and process referrals to the team. 

Please call The Access Point at 416-640-1934 to obtain an application form.  Once the application form is submitted, The Access Point will assess the client for eligibility; if the client meets the eligibility criteria, The Access Point will send the referral to the STEPS team.

CATCH Homeless

CATCH-Homeless is collaboration between St. Michael's Hospital, Inner City Health Associates and Toronto North Support Services.  It connects homeless people presenting to hospital to comprehensive health supports including primary and psychiatric care, peer support and case management.

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CATCH teamServices offered

CATCH Transitional Case Managers (TCMs) are working from the St. Michael's Hospital, Centre for Addiction and Mental Health and St. Joseph's Health Centre.  If on-site, CATCH TCMs will meet with patients in the ED or the inpatient unit immediately upon referral.  If not on-site, CATCH-TCMs will connect with and meet referred clients in the community.  CATCH offers access to timely  primary, psychiatric care, peer support, , and other services to support patients’ access to medical care, mental health and addictions services, housing and other resources in the community.

Eligibility criteria

Homelessness and unmet health or social service needs.

How to access the service

CATCH accepts referrals from partner hospitals. Complete the CATCH referral form and fax it to the CATCH Office at 416-864-5467.  If you don’t know which program would be most appropriate for your patient, or if you have any other questions, call 1-877-482-4595 and one of the program coordinators will answer your questions.

Geriatric Mental Health Outreach Program (GMHOP)

GMHOP provides specialized outreach consultation, assessment and follow up services to older adults with mental health needs and complex behavioral problems who reside in long term care homes in Toronto. The GMHOP team includes a geriatric psychiatrist and a behavioural neurologist as well as a registered nurse and occupational therapist—both of whom specialize in providing geriatric mental health outreach, including consultation, assessment and followup care.

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Geriatric Mental Health  Outreach Program teamServices offered

  • Psychogeriatric assessment and consultation
  • Treatment Recommendations
  • Follow up

Eligibility criteria

Older adults 65 years and over residing in a St. Michael’s Hospital’s designated long term home

How to access the service

Individuals must be referred by the designated Long Term Care Home.  For more information please call 416-864-5120.