This is just a one page Behavior Reflection report that a student can fill out when they need time out. Younger students can draw and label their behavior. There is a place for chosen consequence. There are consequences for inappropriate behavior and students should already know what some of those consequences are: note home, no reward, trip to principal, give up iPad or something that isn't essential to learning, but student enjoys as a privilege.
Hope you can find a use for this in your classroom. Pam