Santa Clara — FM-1073*

Source: https://santaclara.courts.ca.gov/system/files/forms/fm-1073_rem.pdf

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: Date:

Case Number: FCS:

FM-1073 REV 11/25/08 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: Date:

Case Number: FCS:

FM-1073 REV 11/25/08 Page 1 of 1