[The author waves all HIPAA privacy rights and releases this form to be copied, pasted and printed as many times as is medically necessary. The prescription never expires.]
Fill out with any writing implement (fancy black fountain pen, yellow-coated #2 pencil, red nail polish, Harold’s purple crayon, green sharpie used to draw on the dog, burnt umber oil pastel, etc.) available in the hour of need.
Circle all that apply:
Dear Loved One / Responsible Adult Acquaintance / or, at this point, any Sane and Compassionate Appearing Neighbor,
The time has come. I have pushed this stroller / driven this minivan of family bliss to the edge of the sidewalk, and I can go no further.
I have neglected myself – body / spirit / mind to the point of, well…just look at me.
Please take my child / children / me away for an hour / a day / a weekend.
Please do so with great humor and no commentary. Tell me nothing about the time you have with them / call only if they land in the E.R. / on the other hand, maybe don’t even call.
I will be napping / crying / meditating / wandering for the few short hours I will have to myself. I will return a better parent than when I left, and with the pledge that I will endeavor not to let myself crumble to this extent next time before I realize I cannot do this job, the most difficult job on Earth, without the support and care of others around me.
Next time the sidewalk ends.
