1. My name is......................................
2. This plan is to keep me and the following people safe.
3. The Physical signs that I am getting angry are:
3a. When I notice these signs or have them pointed out I will.....
4. The Emotional signs I am getting angry are:
4a.When I notice these signs or have them pointed out I will.....
5. The Behavioural signs that I am getting angry are:
5a.When I notice these signs or have them pointed out I will.....
6. When I am into the cycle of abuse these are the things I do most
6a. If I start to do these things or other abusive things or have it
pointed out that I am doing them I will.....
7. I still hold onto the following beliefs that could make it hard for
me to be non-violent in the future.
8. I learned the following things from hearing from victims of male
violence that made me not want to be violent again.
9. My Time Out strategy that I have agreed with my partner, or worked
out for me(only if you have no partner) is:
10. My support network includes the following people.
This plan should be completed before a crisis occurs and in conjunction with your support people
This page was last modified on January 4th 2001
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11, Kookora St.,
Griffith, NSW 2680