The Healing Separation: Agreement Form (Page 2 of 6) in pdf

Denver Psychotherapy and

Noeticus Counseling Center

Consultation Services, LLC

and Training Institute

Innovative Approaches to Counseling and Change ™

™

Resources for Personal and Professional Growth

• To help me explore what my basic relationship needs are and to help me

determine if these needs can be met in this love relationship.

• To experience the social, sexual, economic, and/or parental stresses which can

occur when I have separated from my partner.

• To allow me to determine if I can work through my process better apart than I can

in the relationship.

• To experience enough emotional distance so I can separate out my issues, which

have probably become convoluted and mixed up together with my partner’s issues

in our relationship.

• To provide an environment to help our relationship heal, transform, and evolve

into a more loving and healthy relationship.

• _________________________________________________________________

C. Specific Decisions Regarding this Healing Separation:

1. Length of Separation:

We agree our separation will begin on (month and day) _______________and end on

(month and day) _______________.

Most couples have a sense of how long the separation they will need or want should

be. It may vary from a few weeks to six months or longer. The length of time agreed

upon may be re-negotiated at any time by the initiation of either partner The length of

time would be good topic for a family meeting or a communication exercise.

2. Time to be Spent Together:

We agree to spend time together when it is agreeable to both parties. This time might

be spent having fun, talking, parenting together, and/or sharing our individual

personal growth processes. We agree to initially meet per the arrangements made for

our family meetings and to re-negotiate the time together as needed. We agree to

discuss and reach an agreement if this time together is to include a continuing sexual

involvement with each other. More specifically, we agree to spend time together in

the following ways:

_____________________________________________________________________

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The Healing Separation: Agreement Form Page 2