Behavior Reflection Sheet (Primary Grades K–2)
Name: _________________________
Date: _________________________
Teacher: ______________________
1. How are you feeling right now?
☐ Happy ☐ Sad ☐ Angry ☐ Frustrated ☐ Tired ☐ Excited
2. What happened?
(What did you do?)
3. Why do you think that happened?
☐ I was upset
☐ I wanted attention
☐ I didn’t know what to do
☐ I didn’t like the rules
☐ I made a mistake
4. What could you do differently next time?
5. Do you want to talk to your teacher or a trusted adult?
☐ Yes ☐ No
✍ My goal is to:
Student Name: ______________________
Date: ______________________
Time Removed: ____________
Return Time: ____________
1. What behavior led to your removal from class?
2. What were you thinking at the time?
3. What have you thought about since then?
4. Who was affected by your actions? How?
5. What can you do to fix the situation (if needed)?
6. What will you do differently moving forward?
7. What support do you need to be successful when you return?
✍ Student Signature: ______________________✍ Staff Signature: ______________________
Name: _________________________
Date: _________________________
Class/Teacher: __________________
1. What behavior led you to fill out this reflection sheet?
2. What rule or expectation did you not follow?
3. What was happening right before the behavior?
4. How did your behavior affect others (classmates, teacher, etc.)?
5. What can you do differently next time?
6. What support might help you make better choices?
☐ Break/Reset time
☐ Help with feelings
☐ Check-in/check-out
☐ Other: __________________________
✍ Student Signature: _________________________
✍ Teacher Notes (if needed):