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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:




                        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: _______________