IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA. Case No.: IN RE: The Marriage of __________________________________, Husband and , Wife [ ] HUSBANDS CONFIDENTIAL COUNSELING STATEMENT [ ] WIFES CONFIDENTIAL COUNSELING STATEMENT I understand that reconciliation services may be available to me through the Court in this county, and if so, I request the following: [ ] I would like marriage counseling. [ ] I would like to talk with a trained person about my present family situation. [ ] I do not desire counseling at this time. _______________________________________ ______________________________Signature of Requesting Party Date Mailing address of requesting party: Address_________________________________ City, State, Zip___________________________ Telephone Number________________________ Fax Number_____________________________ Mailing address of other party: Address_________________________________ City, State, Zip___________________________ Telephone Number________________________ Fax Number_____________________________ Law 1081 - Rev. 12/2004 American LegalNet, Inc. www.USCourtForms.com