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I agree to the following plan to prevent abuse or violence: 

1. I will separate from my family member/s when

  • I start to feel angry or upset and might become hurtful
  • I start to use any hurtful behaviors including the following:

                        Yelling

                        Name-calling/profanity

                        Threats

                        Intimidating behaviors

                         Property damage

                        Unwanted physical contact, such as,

                                  hitting, punching, pushing, kicking,

                                  slapping, grabbing, or other

                                  unwanted contact

                       

2. I will tell the person I am separating by saying:

     _____________________________________________________

 

3. I will separate from the person and go to one of the following places:

______________________________________________________

 

4. While I am separated I will do something to calm myself down, such as:

_______________________________________________________

 

5. I will stay away from others for 15 – 20 minutes, or until I can be safe and respectful to everyone in the house.

 

I agree to the following rules:

 

  • I will not use this to plan as an excuse to leave the house or do things I am not supposed to do.

     

  • After my separation time I will return and make a plan with the other person about what to do next, (i.e., finish the discussion, plan a time later to talk about it, or let it go).

     

  • If the other person separates from me I will respect their time alone and not bother them.

     

  • I will stay away from the other person until they are ready to talk again.

 

I agree to follow this plan to help me stay safe and respectful.

  

___________________________________________________________

Youth Signature            

 

Date: _______________

 

 

Parent Agreement:

     I also agree to be non-violent and to support my youth in following this plan.

 

 ____________________________________________________________

Parent Signature

 

Date: _______________