Behavior Reflection Form

Name: ______________________________________________________
Teacher Referring: ____________________________________________
Date: _______________________________________________________
Directions: Read each question and answer them as thoroughly as possible. Do not
leave out any details and please be honest.
When did my inappropriate behavior occur? Where was it and who was present at the
time?

What bad choice did I make?

What negative outcomes occur when I use unacceptable behavior?

What could I have done instead?

What might positive outcome may occur if I choose an appropriate behavior to handle
my problem?

PLEASE TURN PAPER OVER TO COMPLETE

THE BEHAVIOR REFLECTION FORM.

Letter to Parents and Teacher/Staff

Directions: Use the lines below to write a letter to both your parents and the
teacher/staff member.
The letter you write to your parent will inform them about what happened and
what you learned from this experience.
The letter to the teacher should explain your actions and how you will not display
that inappropriate behavior any more.
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PLEASE TURN IN THIS DOCUMENT TO THE TEACHER UPON COMPLETION AND WAIT FOR
FURTHE DIRECTIONS. THANK YOU.