Behaviour Modification Program
Name: Class:
Step 1 – Recording Disruptive Behaviour
Date Behaviour
Step 2 – Student Interview
Date: Interview Notes:
Student Signature:
Teacher Signatures:
A Unger, R Laugesen
16/07/2008
Step 3 – Glasser Method
Unfortunately you are disrupting the learning of others. You will be given a personal study plan and placed in another classroom. This will occur for a two day period. If you can now study without disrupting the learning of others you may return to class. After one week your progress will be reviewed in another interview. Day 1 Room: Teacher: Study Plan:
Day 2 Room: Teacher: Study Plan:
Step 4 – Student Review
Date: Interview Notes:
Student Signature:
Teacher Signatures:
A Unger, R Laugesen
16/07/2008
US: 
