SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: FOR COURT USE ONLY PETITIONER: RESPONDENT: CASE NUMBER: WAIVER OF RIGHT TO INDIVIDUAL SESSIONS FCS NUMBER: I, (Print your Name) , have declared I am /have been a victim of 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 American LegalNet, Inc. www.FormsWorkFlow.com