Restorative Reset Form
Restorative Reset Form
Reflect • Understand • Repair • Move Forward
Part 1: Reflection & Perspective
Student Name
Date
Class / Period
Facilitating Staff
Take a slow breath. This form is your opportunity to share what happened honestly from your perspective and collaborate on a respectful path forward.
1
Emotional Check-In: Where Was Your Head & Body?
Select all that applied before & during
Overwhelmed Frustrated / Angry Disrespected Embarrassed Ignored / Excluded Confused / Stuck Tired / Anxious Other: _________
Intensity (1=Low, 5=High):
1 2 3 4 5
What triggered this?
2
Your Perspective: What Happened?
Describe the situation from your point of view. What was happening around you, what led up to it, and what did you say or do?
3
Impact & Ripple Effects: Who Was Affected?
Behavior creates ripples. In what ways did this incident affect:
Impact on You (learning, mood, reputation):
Impact on Others (classmates, teacher, space):
Student Restorative Practice Record Page 1 of 2 • Continue on Page 2 for Solutions & Teacher Support
Restorative Action & Partnership
Part 2: Planning Better Choices & Mutual Support
Student:
Date:
4
Better Choices: What Could You Do Differently?
Self-regulation strategies
If you encounter the same frustration, conflict, or stress again, which strategies could you use?
Ask for a 2-minute reset Use deep breathing (4-4-4) Ask for task clarification Write thoughts on scrap paper Request to speak in private Step away from the conflict
My specific choice or response next time:
5
Teacher Support: How Can Staff Help?
Within school & classroom rules
Rules maintain safety and fairness for everyone. Within school rules, what could the teacher do to support you when you are struggling?
Give me a discreet non-verbal cue if tension is rising Allow me a designated cool-down spot before calling on me Check in quietly 1-on-1 rather than speaking across the room Break multi-step assignments into smaller manageable pieces
What is one specific, realistic way the teacher can assist you in meeting classroom expectations?
6
Restoration: Making Things Right
Repairing harm
Restorative practice means repairing relationships or space. What action step will you take to restore trust?
Commitment & Next Steps Follow-up check-in date:
Student Signature
Teacher / Facilitator Signature
Restorative Reset Process • Positive Behavior Support Page 2 of 2
