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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
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