Upsetting Behaviors in Another

Dear _________________,

A behavior that I am most upset about is_________________________________________________________________

_________________________________________________________________________________________________
What behavior? Describe the behavior in detail. When/Where does it happen?
_________________________________________________________________________________________________

_________________________________________________________________________________________________

The impact of this behavior on me is ____________________________________________________________________

_________________________________________________________________________________________________

The needs in me that are not being met by this behavior are _________________________________________________

_________________________________________________________________________________________________

The feelings that I feel about this behavior are____________________________________________________________
Name the feeling words. Circle the main feeling word.

Specifically, the physical sensations that I feel when I feel these feelings are

_________________________________________________________________________________________________
Describe these sensations in various parts of your body. Or describe your physical posture when you feel these feelings.

On a scale of 1 to 10 the intensity of these feelings are about a _______________________________________________

It seems to me that your intentions are __________________________________________________________________

_________________________________________________________________________________________________

When I feel these feelings my inner conversation goes something like _________________________________________

_________________________________________________________________________________________________

The behaviors that I tend to act out when I feel these feelings are _____________________________________________

_________________________________________________________________________________________________

The words that want to come out of my mouth when I feel these feelings are ____________________________________

_________________________________________________________________________________________________

A previous time when I have felt similar feelings was the time when ___________________________________________

_________________________________________________________________________________________________
Could be a time that goes back to childhood or anytime in-between. Could be a time in your relationship together.

My biggest fears in sharing my feelings with you are ______________________________________________________

________________________________________________________________________________________________

What I would like to see happen is _____________________________________________________________________

_________________________________________________________________________________________________