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Decision Points – Feedback Form
Feedback for
Date
MM slash DD slash YYYY
Step One – Identify my thoughts and feelings.
Risk Situation in report?
No
?
Yes
Risk Situation – Comment
3 or more thoughts in report?
No
?
Yes
Thoughts – Comment
1 or more feelings in report?
No
?
Yes
Feelings – Comment
Starred thought and feeling?
No
?
Yes
Starred Thought and Feeling – Comment
Offending or hurtful action in report?
No
?
Yes
Hurtful Action – Comment
Connections between each part of report are clear?
No
?
Yes
Connections – Comment
Step Two: Think about who cares what I do.
3 or more people in report?
No
?
Yes
People Who Care – Comment
What each person would want me to do in report?
No
?
Yes
What People Who Care Would Want – Comment
Step Three: Think about choices. Pick one.
2 or more choices in report?
No
?
Yes
Choices – Comment
Each choice coded?
No
?
Yes
Coded Red, Yellow, Green – Comment
Feel OK each choice?
No
?
Yes
Coded Feel OK – Comment
Best choice chosen?
No
?
Yes
Best Choice – Comment
Step Four: Identify a motivating thought.
3 or more motivating thoughts in report?
No
?
Yes
Motivating Thoughts – Comment
Thoughts support choice?
No
?
Yes
Support Choice? – Comment
Summary
Steps to Practice?
Step One
Step Two
Step Three
Step Four
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