COUNSELLING CERTIFICATE FOR APPLICANTS MARRIED LESS THAN 2 YEARS
Part A	The parties 	
1.	Applicant
	(names as used now)	Family name       
Given names       	
2.	Applicant 2/ Respondent 
	(names as used now)	Family name       
Given names       	
3.	Date of marriage
	(day / month / year)	     /      /     	
4.	Date of separation 
(day / month / year)     /      /     	
Part B	Family counsellor or other specified person	
5.	Name	Family name	     
Given names	     	
6.	Organisation	     	
7.	Address of organisation	     	
8.	Details of counselling	     	

Part C	Certificates – complete one section only	
Section 44(1B) Family Law Act 1975
I certify that both the Applicant and Applicant 2/Respondent attended the counselling set out in question 8 and considered reconciliation.	Section 44(1C) Family Law Act 1975
I certify that:
(a)	Only the  applicant  applicant 2/respondent attended the counselling set out in question 8 and considered reconciliation, and
(b)	The  applicant  applicant 2/respondent was invited to attend the counselling to consider reconciliation but did not.	
Signature	Signature	
     
Full name	     
Full name	
     
Position	     
Position	
Date	     /      /     	Date	     /      /     	
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