I have a couple of students that really struggle with asking for breaks. As teachers, we learn to recognize their triggers and their anxiety in order to help curb any escalations. I created these break passes for several reasons:
1) To provide a POSITIVE break to those that have earned it. My students LOVE going down to hang out with the principal or dean for a positive reward and it usually means they get a special treat
2) To quickly and effectively communicate to office staff if a student needs to cool down outside of the classroom. Before I was spending precious moments writing out detailed memos to admin about triggers and such where now I can just check a box.
I print these on colored paper and cut them to half sheet size. Mine have my name listed in the lower right corner which could easily be handwritten in if you choose.