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NWT Form 22: Assisted Community Treatment Certificate

This certificate lets an involuntary patient in the Northwest Territories live outside the designated facility while receiving supervision, treatment or care under a Form 23 Community Treatment Plan. The patient remains an involuntary patient of the facility. The attending medical practitioner issues it after examining the patient within the past 72 hours, and each certificate or renewal lasts no more than six months.

Who completes it

The attending medical practitioner completes the certificate, lists all previous consecutive ACT certificates, confirms the five criteria with supporting facts and signs. The patient signs, and so does the substitute decision maker if applicable.

Submitting and payment

How to submit it
The certificate and the appended Community Treatment Plan must be filed with the director of the designated facility within 24 hours, with copies to the patient and others listed, such as the substitute decision maker or a person designated to receive information.

Good to know

  • All five criteria apply: a mental disorder needing supervision and treatment or care in the community, likely harm or deterioration without it, capacity and willingness to comply with the plan, and adequate available services.
  • Before issuing it, the practitioner gives the director Form 21, Notice of Intention to Issue Assisted Community Treatment Certificate, and collects patient, monitor and provider consents for the Form 23 plan.
  • Changes to the certificate use Form 25 and changes to the plan use Form 26. The supervising medical practitioner may require the patient to return if their condition or supports change.
  • Renewal is done by issuing a new Form 22. If the patient must instead return to the facility at expiry, Form 29 notice is given 14 days before the certificate expires.

Get the official form

Download the current version from the source each time; forms change without notice.

Form 22 - Assisted Community Treatment Certificate

Formule 22 - Certificat de traitement en milieu communautaire assisté

Official pagePDFVersion française

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

How long is an Assisted Community Treatment Certificate valid in the NWT?

Each certificate or renewal may not exceed six months. It also ends automatically if the patient stops being an involuntary patient under a Certificate of Involuntary Admission or Renewal Certificate, and it can be cancelled with Form 28 or by a Review Board panel.

Does the patient have to agree to assisted community treatment?

Yes. One of the criteria is that the patient is willing to comply with the Community Treatment Plan, and the patient, or the substitute decision maker if applicable, signs both the certificate and the Community Treatment Plan patient consent form attached to Form 23.

Is Form 22 available in French?

Yes. Formule 22, Certificat de traitement en milieu communautaire assisté, is a separate French PDF with the same catalogue number, NWT9073, published by the Department of Health and Social Services with the other Mental Health Act forms.