Teacher and Student Check-In

Echo Glen: Teacher and Student Check-In

Student Name:

Date:

1. Current grad in this class (grade & %) =

2. What is going well for the student in class?

3. On a scale of 1-3, rate how much the items below impacts your academic performance:

Potential Obstacle	No Impact	Some Impact	High Impact
Attendance (tardies/skipping/unexcused absences)	1	2	3
Missing assignments	1	2	3
Lack of motivation	1	2	3
Lack of interest in the subject	1	2	3
Performance on tests	1	2	3
Outside factors (family, personal, social)	1	2	3

Interventions

What are 2 or 3 specific things you’d be willing to do in the next few weeks that would make the most positive impact on your current grade?

Do you have any questions about any upcoming or past assignments(s) that will help you complete your assignment(s) with more success?

Do you have any questions about previous tests or upcoming tests that will help prepare you to be more successful on your tests?

What is one DBT skill that will help you be successful in the classroom?

What way can I help you use this DBT skill in the classroom?

What is one goal you plan to achieve in the next two weeks?

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