Student Name: ______________________________________ Date: __________

Sending Teacher: ___________________________________ Time Sent: __________

CHAMPION Room
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Restorative Reflection Questions

1. Describe the things you feel you were doing well today since school started:

I was discovering my learning by...

I was flourishing my relationships by...

I was empowering compassion for others by...

I was preparing to navigate our world by...

2. ​When did you start to struggle​ ​(What behavior was not okay; why were you removed?)​ ​ ​I started to struggle when...
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3. ​If you were in the same situation tomorrow, are you more likely to follow the expectation or break the expectation? Why?
In this same situation I would...
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4.​ Is this the first time you have struggled with this behavior?​ (circle one) YES NO

5. ​How did my behavior affect others?​ ​ I know my behavior affected others because...
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6.​ How can I help you be more successful?​ ​ As the teacher, you could help me by...
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7.​ How can you fix this situation (Whom, Words/Tone, Body Language, and Actions)? ​ I can fix this situation by...
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*************************************************** CHAMPION TEACHER USE ONLY ***************************************************

Champion’s Signature: ___________________________________________ Time Student Left Champion Room: _______

Sending Teacher Reminders​:

❏ Submit a log entry that the student was sent to the Champion Room and describe why.
❏ Process with the student within 24 hours (submit another log entry on how it went)
❏ Keep this for your records in the Champion Room Folder