DAILY BEHAVIOR
SELF MONITORING SYSTEM



The below form is a sample form from a parent. This form has been used with her son and he has done quite well using it.  On the form below there is a chart with eight periods where the teachers initial if the child meets his targets for that period.  You are welcome to use this form as a guide when assisting your son.

              Periods           1    2    3    4    5    6    7    8
         
           Teacher's initials  ______
 
 
Date:________________                                    Name:__________________
                                                                    
 Targets:                                                    
I asked for help.                                
I used self control.
I tried when it was hard.
I used positive body language.
______________________                                ________________________
Student signature                                                   Teacher signature
 
Three positive things about my day.
1.__________________________________________________________________
 
2.__________________________________________________________________
 
3.__________________________________________________________________
 
Today I made __________(good/poor) choices. Tomorrow I am going to ___________
 
____________________________________________________________________
 
When I make good choices I ___________________________________(how I feel)
 


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Last updated on June 5, 2010