District No.

E.F., of …………… Prosecutor

A.B., ……………… Accused

Before the District Court at ........... within the District Court area aforesaid

A.B., of …………… hereinafter called the accused, is this day convicted *(the accused having been informed of his/her right to be tried by jury and having consented to be dealt with summarily)

That he/she, on the … day of ………. 20., at ............

Within the ………… aforesaid did (here state the offence).

And the accused having been convicted of the said offence and sentenced to a period of *imprisonment *detention

IT IS FURTHER ORDERED that during the period of ...... commencing upon the date of his/her release from *imprisonment *detention the accused shall remain under the supervision of ..........., a probation and welfare officer, while this Order shall remain in force.

And having regard to section 28 and section 30 of the above-mentioned Act, it is further ordered that following his/her release from *imprisonment /*detention and while this Order shall remain in force

*The said accused be prohibited from

*The said accused undergo the following*counselling *treatment provided by

And this Order shall remain in force from the … Day of ………., 20… to the …. day of …….., 20….

Dated this … day of …………… 20…..

Signed ……………

Judge of the District Court

*warrant of execution as to imprisonment *detention in the usual form