2 copies to be filled out separately (one for offender/one for safe guard)

1. Within our relationship, major areas of agreement are the following. (Use extra paper if needed and attach)

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2. Within our relationship major areas of disagreement are the following:

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3. Our areas of disagreement are usually resolved in the following manner(s):

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4. In the future I would like to see our major areas of disagreement resolved in the following manner:

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Signature: ____________________________Date:___________________