Behavior Reflection Sheet

Name ________________________

Date _______________________

Today during _________________________ I made the choice to ____________

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________.
Instead, I should have been ___________________________________________
_________________________________________________________________.

I made this choice because ___________________________________________

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
My choice impacted my learning or the learning of others because _____________
_________________________________________________________________
_________________________________________________________________.

I think that a fair consequence would be _________________________________

_________________________________________________________________
_________________________________________________________________.
Next time I can be proactive by _______________________________________
_________________________________________________________________
_________________________________________________________________
________________________________ so that this problem doesnt happen again.
Student Signature ________________________________________
Teacher Signature _______________________________________
Parent Signature ________________________________________
Parent contacted by phone

Mother

Father