Name of patient :

Birth place & date :

Name of doctor :

Medical Practice :

Medical Address :

Dear Enforcement Authorities / Local Doctor,

My patient has been diagnosed with:

1. Autism Spectrum Disorder (ASD), he has an issue with his attention especially about receiving
instruction.
2. He’s been doing Behavior Therapy at (Name of medical institution) for (duration of therapy)
follow up treatment is imperative for the child
3. For the reason that he has an issue about receiving instruction and still doing activities that
might endanger his safety so he need to be handled by at least 2 (two) adults.

In Summary follow up treatment is medically necessary for this patient’s medical condition and need 2
adults to monitor the child development (preferably parents).

Sincerely

Doctor signature

(Doctor’s name)