Time-Out Protocol Plan - Google Forms

Our relationship safety plan when things heat up Required
Partner A: Triggers, Feelings & Behaviours that lead to escalation feeling out of 1. control
1. Partner A: Triggers, Feelings & Behaviours that lead to escalation feeling out of control
Partner B: Triggers, Feelings & Behaviours that lead to escalation feeling out of 2. control
2. Partner B: Triggers, Feelings & Behaviours that lead to escalation feeling out of control **
First to Recognize and Call Time-Out Signal
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WWhhoo wwiillll ddoo tthhiiss??Partner APartner B
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4. Time Out Signal
How to Separate: when we separate, Partner A will go: 5.
5. How to Separate: when we separate, Partner A will go:
When we separate, Partner B will go:
6. When we separate, Partner B will go:
Separation Period Time: the amount of time we agree on is: 7.
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20 minutes30 minutes60 minutes
Tick all that apply.

calming downgetting curious about your partner
9. How Partner A calms down:
10. How Partner B calms down:
Partner A: What I think is going on for my partner (B):
11. Partner A: What I think is going on for my partner (B): *
Partner B: What I think is going on for my partner (A):
12. Partner B: What I think is going on for my partner (A):
Tick all that apply.

reconnection: text, call, and/or face to facequick repair - apologize for any hurtful behaviourextend time-out if neededmake a dialogue appointment
Tick all that apply.

Other:
14. Plan to Reunite Notes *
Should be Empty:

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