FORM 81A-V
rule 81A.41(15)
File No: [file number]
HOSPITAL OR TREATMENT ORDER
[Offender's full name]
of [address] was on [date] dealt with by the Supreme Court at [Darwin / Alice Springs] which recorded a conviction for the offences shown below:
CASE & OFFENCE NOS	
OFFENCE	
File number	[No]	[offence]	

AND, amongst other things, it was ordered under [section 80 of the Sentencing Act 1995 / section 82 of the Sentencing Act 1995 / section 22 of the Crimes Act 1914 of the Commonwealth] that the offender: 
[state details of the diagnosis, assessment and/or treatment that the offender is ordered to undertake and any other relevant orders made]
This order starts on [date] and ends on [date].
Date: [date]

A copy of this order must be given to the offender and the Director