Page 11 - Restorative Practices Implementation Guide - Introductory Version

Appendix
Program Intake Form
RP PROGRAM INTAKE
Date: _____________________ Student: _____________________
What happened? ________________________________________________________________________ ________________________________________________________________________
What were you thinking about at the time? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
What have you thought about since? ________________________________________________________________________
Who has been affected by what you have done? In what way? ________________________________________________________________________
Have I apologized to those affected by my behavior: _____ Yes ______ No
What do you think you need to do to make things right? ________________________________________________________________________
Student Signature: ___________________ RPC Signature: _____________________ Teacher Signature: ___________________
RPC Behavior Intervention
11