The below form is a sample form from a parent. This form has been used with her son, who has done quite well. On the form below is a chart with eight periods where the teachers initial if the child meets his targets. 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)
