Behavior Reflection Form

W.A. Pattillo Middle School

Name: ______________________________________________________
Teacher Referring: ____________________________________________
Date: _______________________________________________________

Directions: Read each question and answer them as thoroughly as possible. Do not leave out any details and
please be honest.

When did my inappropriate behavior occur? Where was it and who was present at the time?

What bad choice did I make?

What negative outcomes occur when I use unacceptable behavior?

What could I have done instead?

What might positive outcome may occur if I choose an appropriate behavior to handle my problem?

Write a complete paragraph that states why you were sent out of class to the time-out area:

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What could happen to you in the future if you keep choosing not to follow the rules in class?

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Explain why you should value your education. Remember, your education is what you make of it
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Think about why you broke the rules in your classroom. Check all that apply:

I wanted attention from my classmates or my teacher.

I was frustrated with the work and did not know how to ask for help
I wanted to get out of doing my work.
I was finished with my work and was bored
I was scared about not being successful on my assignment so I didnt start it.
I am angry about something that is going on in class (not the work)
I am angry/upset about something outside of class (at home or in other classes)
I dont feel well
I wanted to avoid the teacher or someone in my class.
I wanted to show the class that I was tough or in control.

Return to Ms. Jenkins and begin your class work. Do not put your head down. If
you choose to be disruptive you will get a referral.

Student Name: ____________________ Date: ____________________________