Refocus Form
Name ____________________________________________________________________________ Date ______________________
Teacher _____________________________
Please think about what caused you to be removed from class and write in the spaces provided.
I made some choices today that caused me to be removed from the rest of the class. I accept
responsibility for my behavior. Here are the choices that I made:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Here are some ideas I have for how to behave differently the next time that I am in a similar situation.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
When you have completed these two sections, and feel ready to return to class, you may:
1. Turn this paper over on the table 2. Wait for the teacher to invite you to return to your seat
Refocus Form
Name ____________________________________________________________________________ Date ______________________
Teacher _____________________________
Please think about what caused you to be removed from class and write in the spaces provided.
I made some choices today that caused me to be removed from the rest of the class. I accept
responsibility for my behavior. Here are the choices that I made:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Here are some ideas I have for how to behave differently the next time that I am in a similar situation.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
When you have completed these two sections, and feel ready to return to class, you may:
1. Turn this paper over on the table 2. Wait for the teacher to invite you to return to your seat
I have decided to change my behavior; I am
ready to return to class.
I have decided to change my behavior; I am
ready to return to class.