Behavior Improvement Form
Name __________________________
Date ___________________
Did you follow directions appropriately? Yes _____ No _____
What was your behavior? ______________________________________
_________________________________________________________
_________________________________________________________
What did you want? (put a check next to the appropriate statement)
____ I wanted attention from others.
____ I wanted to be in control.
____ I wanted to avoid doing my homework.
____ I wanted to cause problems because I am sad inside.
____ I wanted to cause other problems because they don’t like
me.
____ I wanted ___________________________________
Did you get what you wanted? Yes _____
No _____
What could you do differently? _________________________________
_________________________________________________________
_________________________________________________________
Will you be able to return to class appropriately? Yes _____ No _____
Student Signature _____________ Teacher Signature _____________