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This worksheet helps you write down a choice about your own contact. It does not tell you to leave, stay, block someone or wait a particular number of days. You can leave questions blank and change your plan.
Reading alongside this worksheet: Attachment, contact and boundaries after a breakup.
A period of space, limited contact and one planned conversation are different choices. Shared responsibilities may require a practical channel.
Focus on what you will do. Another person may disagree; a boundary is not a way to control their response.
A short, specific plan can be easier to follow than a rule for the rest of your life. Necessary contact is not a failure or a reset of progress.
Attachment Shift · September 8, 2026 · Free for personal use. Keep completed copies somewhere suitable for your privacy. This blank worksheet does not collect or submit answers.