SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
B
RANCH NAME:
PETITIONER:
RESPONDENT:
FOR COURT USE ONLY
WAIVER OF RIGHT TO INDIVIDUAL SESSIONS
CASE NUMBER:
FCS NUMBER:
I,
, have declared I am /have been a victim of
(Print your Name)
Domestic Violence, or have a protective order. I have been informed and I understand that I
have the option to meet with the mediator separately from the other parent and at separate
times. I decline that option and wish to be seen together with the other parent.
Signature: Date:
I, , have completed the differential Domestic
Violence Assessment and have met with the parents separately.
Signature: Date:
FM-1072 REV
11/25/08
WAIVER OF RIGHT TO INDIVIDUAL SESSIONS Page 1 of 1
201 North First Street, San José, CA 95113
San José, California 95113
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