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 ______
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:
Today I made __________(good/poor) choices. Tomorrow I am going to ___________
When I make good choices I ___________________________________(how I feel)