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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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