MAD-FCS-0012 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/07/19) Page 1 STATE OF CALIFORNIA MADERA SUPERIOR COURT Family Court Services 200 South G Street Madera, CA 93637 PH #: (559) 416-5560 FAX #: (559) 673-8216 CASE #: NEXT COURT DATE: FCS #: I, ,have declared I am/have been a victim of Domestic Violence, (Print your Name) and I have a Domestic Violence Restraining Order and/or a Criminal Protective Order protecting me and restraining the other party. I have been informed and I understand that Family Court Services schedules parties to meet with the Child Custody Recommending Counselor separately from the other parent and at separate times. I decline that option and wish to be seen together with the other parent in a conjoint session. Signature: Date: WAIVER OF RIGHT TO INDIVIDUAL SESSION Revised February 2019 American LegalNet, Inc. www.FormsWorkFlow.com