SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA Family Court Services 201 North First Street San José, California 95113 (408) 534-5760 WAIVER OF MEDIATION CONFIDENTIALITY I understand that mediation counseling is a confidential process. However, I agree to waive confidentiality in order that the mediation counselor may conduct an assessment/evaluation and to provide the Court with information and recommendation regarding my children. Signature: Case Number: FM-1073 REV 11/25/08 Date: FCS: Page 1 of 1 SUPERIOR COURT, STATE OF CALIFORNIA COUNTY OF SANTA CLARA Family Court Services 201 North First Street San José, California 95113 (408) 534-5760 WAIVER OF MEDIATION CONFIDENTIALITY I understand that mediation counseling is a confidential process. However, I agree to waive confidentiality in order that the mediation counselor may conduct an assessment/evaluation and to provide the Court with information and recommendation regarding my children. Signature: Case Number: Date: FCS: FM-1073 REV 11/25/08 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com