Respondent FCS Date A PARTY ALLEGING A HISTORY OF DOMESTIC VIOLENCE AND NOT COVERED BY A PROTECTIVE ORDER MAY REQUEST A SEPARATE MEETING TIME WITH A FAMILY COURT SERVICES COUNSELOR BY COMPLETING THIS FORM. COMPLETE AND RETURN THIS FORM TO FAMILY COURT SERVICES AT THE ADDRESS CHECKED ABOVE. I, _________________________________________________, am the petitioner respondent in the above- entitled case. I request a separate meeting with the Family Court Services Child Custody Recommending Counselor as authorized in Family Code

section because of a history of domestic violence with the other party. Family Code

section defines abuse as: 1. To intentionally or recklessly cause or attempt to cause bodily injury. 2. Sexual assault. 3. To place a person in reasonable apprehension of imminent serious bodily injury to that person or to another. 4. To engage in any behavior that has been or could be enjoined pursuant to Family Code

section described as follows: • Molesting • Attacking • Striking • Stalking • Threatening • Harassing • Battering • Assaulting (sexual or otherwise) • Credibly impersonating (on the Internet, electronically or otherwise) as described in Pen. Code, § 528.5 • Falsely personating as described in Pen. Code, § 529 • Telephoning, including, but not limited to, making annoying telephone calls as described in Pen.

Code, § 653m • Destroying personal property • Contacting, either directly or indirectly, by mail or otherwise • Coming within a specified distance • Disturbing the peace of the other party • Coercive control of the other party.

Examples include but are not limited to: o Isolation from sources of support o Deprivation of basic necessities o Monitoring or controlling the other party’s daily behaviors o Intimidation or threats based on actual or suspected immigration status o Reproductive coercion: control over the reproductive autonomy of another through force, threat of force, or intimidation I declare under penalty of perjury under the laws of the State of California that I have been a victim of abuse, as defined in Family Code 6203. Date: Signature of Declarant