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Behavior reflection form teacher and student

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Page 1: Behavior reflection form teacher and student

(subject )

Today in ______________________ class I made a poor choice. My poor choice was my decision to ________________________________ ________________________________________________________________ ________________________________________________________________ The events that led up to my poor choice were ___________________________________________ _________________________________________________________________________________________

________________________________________________________________________________________ ________________________________________________________________________________________ __________________________________________________________________________ _________________________________________________________________________ Next time I will change my actions by _______________________________________ _____________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ The consequence(s) of my actions should be ____________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Student Name: Grade: Teacher:

Parents: Please review the back of this page for teacher observations and recommendations.

STUDENT BEHAVIOR REFLECTION

Created by Amy Bultena www.artfulartsyamy.com @artfulartsyamy

Page 2: Behavior reflection form teacher and student

Student Name: Grade: Teacher:

Teacher observations of situation leading to student reflection _______ __________________________________________________________________ _____________________________________________________________________

__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________

Actions taken by the teacher ____________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________

Teacher reflections on student-chosen consequence and/or teacher assigned consequence __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________

Number of times student has completed the Behavior Reflection form during ________ term. __________________________________________________________________________________________________________

Overall impact on student’s conduct grade _______________________________________________ __________________________________________________________________________________________________________

This form is used to help students reflect upon choices made in the classroom, and to help them devise better

solutions the next time such a situation should arise.

Guardian Signature _________________________________________________ Date _____________

TEACHER BEHAVIOR REFLECTION

Created by Amy Bultena www.artfulartsyamy.com @artfulartsyamy