1)   The clues that _________________ is getting angry are:

    (Husband)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2)   The clues that _________________ is getting angry are:

      (Wife)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3)   The “triggers” we need to avoid are:

His: ____________________________________________________________________________________________________________________________________________________

Hers: ____________________________________________________________________________________________________________________________________________________

4)   The neutral, non-blaming time-out signal we will use is:

____________________________________________________________________________________________________________________________________________________

5)   When either of us gives the signal:

___________________  will go  ______________________________________

       (Husband)

___________________  will go ______________________________________

          (Wife)

6)   The time-out period will last: ____________________________________

7)   At the end of the time-out we will: __________________________________

_______________________________________________________________

8)   During the time-out period we will observe the following rules:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________

SIGNED:

_______________________________        ___________________________

              (Husband)                                                       (Wife)

_______________________________        ___________________________

              (Witness)                                                        (Date)