Name: __________________________ Date: __________________
Reflection Sheet
How am I feeling right now? (Check all that apply.)
❏ Annoyed ❏ Silly ❏ Scared
❏ Sad ❏ Angry ❏ Calm
❏ Frustrated ❏ Happy
Which classroom expectation did I not meet?
❏ Respect (for me, you, and everyone)
❏ Keep it Safe
❏ Listen and Follow Directions
What did I choose to do that broke the expectation? (Be detailed.)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What did you need that caused this? (Shade the box or boxes that apply.)
Help Attention Control To get out of work
To get even with Talk to the teacher Challenge the Other:
someone teacher
My choices affected: (Check all that apply.)
❏ Myself ❏ My Classmate(s) ❏ My Teacher
Did you have a coping strategy? If yes, circle what you tried. If no, underline
what you could have tried.
Take 3 deep breaths Ignore Count backwards
Ask to move seats Positive Self-talk Do something else
Think calm thoughts Talk to teacher Take a break
Name: __________________________ Date: __________________
What do I need to do to correct the problem?
❏ Apologize
❏ Make a plan
❏ Clean up
❏ Problem solve
❏ Complete work
❏ Do something nice
Is there anything else I would like to tell the teacher?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Student’s Signature: ___________________________
Teacher’s Signature: ___________________________
Now it’s time to come back to the lesson! Raise your hand and I will collect your reflection
sheet. I am glad to have you back and look forward to finishing our class strong!
With love,
Srta. Young