The Healing Separation: Agreement Form printable pdf download

Denver Psychotherapy and

Noeticus Counseling Center

Consultation Services, LLC

and Training Institute

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THE HEALING SEPARATION:

AGREEMENT FORM

Adapted from Rebuilding: When Your Relationship Ends (2

ed)

by Bruce Fisher, PhD

A healing separation is a very challenging experience, which may result in increased stress and

anxiety for both partners. Some structure and awareness can help improve the chances of success

of the healing separation. Unplanned and unstructured separations will most likely contribute to

the ending of the relationship. This healing separation agreement attempts to provide structure

and guidelines to help make the separation a more constructive and creative experience, and to

greatly enhance the growth of the relationship rather than contributing to its demise.

For the sake of clarity throughout this Agreement Form, the following distinctions will be made:

Partner A refers to: ____________________________________________________________

Partner B refers to: ____________________________________________________________

A. Commitment to do a Healing Separation:

With the awareness that our love relationship is at a point of crisis, we choose to try a

working and creative healing separation in order to obtain a better individual perspective

of the future of our relationship. In choosing this healing separation, it is acknowledged

there are aspects in our relationship that are destructive to us as a couple and as

individuals. Likewise we acknowledge there are positive and constructive elements in our

relationship which could be called assets and upon which we may be able to build a new

and different relationship. With this in mind, we are committed to do the personal, social,

psychological, and spiritual work necessary to make this separation a healing one.

We agree that at some future time, when we have experienced the personal growth, self-

exploration, and differentiation possible in a healing separation, we will make a more

enlightened decision about the future of our love relationship.

B. Goals of Our Healing Separation:

Each of us agrees to the following goals for this separation:

• To provide time and emotional space outside of the love relationship so I can

enhance my personal, social, spiritual, and emotional growth.

• To better identify my needs, wants, and expectations of the love relationship.

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The Healing Separation: Agreement Form