"Healing Separation: Agreement Form - Denver Psychotherapy and Consultation Services, Llc"

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Denver Psychotherapy and
Noeticus Counseling Center
Consultation Services, LLC
and Training Institute
®
®
Innovative Approaches to Counseling and Change ™
Resources for Personal and Professional Growth
THE HEALING SEPARATION:
AGREEMENT FORM
nd
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.
th
131 West 10
Avenue • Denver CO 80204-4013 • Phone 303-399-9988 • Fax 303-399-9977
Denver Psychotherapy and Consultation Services, LLC •
info@dpcsonline.com
or
www.dpcsonline.com
Noeticus Counseling Center and Training Institute •
info@noeticus.org
or
www.noeticus.org
Denver Psychotherapy and
Noeticus Counseling Center
Consultation Services, LLC
and Training Institute
®
®
Innovative Approaches to Counseling and Change ™
Resources for Personal and Professional Growth
THE HEALING SEPARATION:
AGREEMENT FORM
nd
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.
th
131 West 10
Avenue • Denver CO 80204-4013 • Phone 303-399-9988 • Fax 303-399-9977
Denver Psychotherapy and Consultation Services, LLC •
info@dpcsonline.com
or
www.dpcsonline.com
Noeticus Counseling Center and Training Institute •
info@noeticus.org
or
www.noeticus.org
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:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
- Page 2 of 6 -
Denver Psychotherapy and
Noeticus Counseling Center
Consultation Services, LLC
and Training Institute
®
®
Innovative Approaches to Counseling and Change ™
Resources for Personal and Professional Growth
A Healing Separation ideally should include some quality time together on a regular
basis. Some people will enjoy their new-found freedom and desire very little quality
time. On the other hand, when the person needing more emotional space separates,
he or she may want more time together. This may be confusing to the person who
didn't desire the Healing Separation. Partners who feel suffocated emotionally
desperately want out. But when they get out of what feels like a tight place, the need
for emotional space is decreased tremendously.
It is important that the time together be quality time and that it be spent creating a
new relationship. When the old pattern starts occurring in whatever forms that may
take, one solution is to end the quality time together and be apart. There are
arguments for and against a continued sexual involvement with each other. Ideally
sexual contact will enhance intimacy and make the separation less stressful and
hurtful. Sex can, however, result in more problems, such as creating confusion for the
potential person being left if the person leaving is just trying to “let me down easy.”
3. Personal Growth Experiences:
Partner A agrees to participate in:
____ individual counseling
____ couple/marriage counseling
____ other personal growth experiences (reading books, journaling, exercise
program, growth group)
____ other: ______________________________
Partner B agrees to participate in:
____ individual counseling
____ couple/marriage counseling
____ other personal growth experiences (reading books, journaling, exercise
program, growth group)
____ other: ______________________________
4. Relationships and Involvements Outside of the Relationship:
Partner A agrees to:
____ develop a support system of important friends
____ become more involved socially with others
____ remain emotionally monogamous
____ remain sexually monogamous
____ become involved in clubs, church singles groups, etc.
____ other: ______________________________
- Page 3 of 6 -
Denver Psychotherapy and
Noeticus Counseling Center
Consultation Services, LLC
and Training Institute
®
®
Innovative Approaches to Counseling and Change ™
Resources for Personal and Professional Growth
Partner B agrees to:
____ develop a support system of important friends
____ become more involved socially with others
____ remain emotionally monogamous
____ remain sexually monogamous
____ become involved in clubs, church singles groups, etc.
____ other: ______________________________
Ideally a joint decision and compromise should be made concerning social
involvement, romantic, and sexual relationships outside of this relationship.
5. Living Arrangements:
Partner A agrees to:
____ remain in the family home
____ move and find an alternative living arrangement
____ alternate living with partner so the children can remain in family home
____ other: ______________________________
Partner B agrees to:
____ remain in the family home
____ move and find an alternative living arrangement
____ alternate living with partner so the children can remain in family home
____ other: ______________________________
In-house separation, with both parties continuing to live in the family home,
frequently results in a less creative experience. It seems to dilute the separation
experience and keeps both parties from experiencing as much personal growth as is
possible with separate living arrangements. It may not give enough emotional space
to the person who needs more space.
6. Financial Decisions:
Partner A agrees to:
____ maintain joint checking account jointly
____ maintain joint checking account separately
____ open new checking account
____ pay auto expenses
____ pay household living expenses
____ pay child support of $_________ monthly
____ pay home mortgage and utilities
____ pay medical and dental bills
____ other: ______________________________
- Page 4 of 6 -
Denver Psychotherapy and
Noeticus Counseling Center
Consultation Services, LLC
and Training Institute
®
®
Innovative Approaches to Counseling and Change ™
Resources for Personal and Professional Growth
Partner B agrees to:
____ maintain joint checking account jointly
____ maintain joint checking account separately
____ open new checking account
____ pay auto expenses
____ pay household living expenses
____ pay child support of $_________ monthly
____ pay home mortgage and utilities
____ pay medical and dental bills
____ other: ______________________________
Often in unplanned, unstructured separations, one person will completely close out
checking accounts and savings accounts without the other person’s knowledge or
consent. If there is any chance for potential disagreement, each person should take
out half of the assets and both can then open separate accounts.
D. Children Involved in this Relationship:
We agree to:
____ joint custody
____ solo or physical custody be given to: ______________________________
We agree to the following or attached visitation schedule.
The medical and dental expenses and health insurance will be the responsibility of
partner ______________________________.
We agree to the following suggestions, designed to help the healing separation be a
positive experience for our children:
1. Both parents remain committed to maintaining a good quality relationship with
each child involved. Each child should continue to feel loved by both parents.
2. Parents should be as open and honest with the children about the Healing
Separation as is appropriate.
3. The parents will help the children see and understand that the physical separation
is an adult problem and that the children are not responsible for the problems in
the parent's love relationship.
4. The parents will not express anger or negative feelings towards the other parent
through the children. It is very destructive to children to become caught in the
emotional crossfire of the parents.
5. The parent will avoid forcing the children to take sides in the parental arguments
concerning differing attitudes and viewpoints.
- Page 5 of 6 -