Stabilization Release Worksheet
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Stabilization Release Worksheet
- 1. Student Name: Date: Staff Signature___________________________ Student Signature________________________________ Stabilization Release Worksheet-‐ Red Sheet, Day 1 General Instructions: All three sheets (Days 1-‐3) must be completed in order to be released from stabilization. Patients must fill out each sheet on the corresponding day (Day 1 = Sheet 1 etc.) and can only fill out 1 sheet per day. If patients refuse, 1 new sheet will be provided every day until completed. Patients cannot receive drawing paper, a book, or other activities until the sheet for that day is completed. Instructions for Red Sheet, Day 1: All questions must be answered completely by the patient. Thoughtful answers are the only acceptable answers and will be passed off by a designated staff member. Day 1 questions deal with the patient’s responsibility for his actions. If any answers contain phrases that blame other peers or staff, the answers will not be accepted and the patient must try again the next day I Am Responsible For My Actions and Feelings 1) I am probably partially blaming staff or a peer for what happened, who am I choosing to blame for my feelings and actions? ___________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 2) To follow up with question 2, why did I choose to blame someone else instead of taking responsibility for my own actions? _________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 3) If I am truly honest about being responsible for my actions, I must ask myself questions like: Did I choose to get upset about something a peer said? Did I assault a peer or staff? Did I get out of control with my language and interactions with others? Did I choose to self-‐harm to the point that staff had to stop me? Was I becoming a danger to myself or others in any way? Student must provide at least 5 sentences describing his feelings and actions that led to him being in stabilization. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
- 2. Student Name: Date: Staff Signature___________________________ Student Signature________________________________ Stabilization Release Worksheet-‐ Yellow Sheet, Day 2 General Instructions: All three sheets (Days 1-‐3) must be completed in order to be released from stabilization. Patients must fill out each sheet on the corresponding day (Day 1 = Sheet 1 etc.) and can only fill out 1 sheet per day. If patients refuse, 1 new sheet will be provided every day until completed. Patients cannot receive drawing paper, a book, or other activities until the sheet for that day is completed. Instructions for Yellow Sheet, Day 2: All questions must be answered completely by the patient. Thoughtful answers are the only acceptable answers and will be passed off by a designated staff member. Day 2 questions deal with what the patient could have done better to prevent this from happening. If any answers contain phrases that blame other peers or staff, the answers will not be accepted and the patient must try again the next day. I Could Have Controlled My Actions and Feelings Better 1) I was probably breaking some rules that could have kept me from getting so upset, what rules could I have followed better to help prevent this from happening (ex. line-‐structure, rough-‐housing, swearing, touching peers, being too loud)? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 2) I have been taught several coping skills to help me when I’m upset, what are 5 coping skills I could have used instead of doing what I did? _____________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 3) In general, what could I have done differently in that situation instead of getting so upset? Student must provide at least 5 sentences describing what he could have done differently. ____________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
- 3. Student Name: Date: Staff Signature___________________________ Student Signature________________________________ Stabilization Release Worksheet-‐ Green Sheet, Day 3 General Instructions: All three sheets (Days 1-‐3) must be completed in order to be released from stabilization. Patients must fill out each sheet on the corresponding day (Day 1 = Sheet 1 etc.) and can only fill out 1 sheet per day. If patients refuse, 1 new sheet will be provided every day until completed. Patients cannot receive drawing paper, a book, or other activities until the sheet for that day is completed. Instructions for Green Sheet, Day 3: All questions must be answered completely by the patient. Thoughtful answers are the only acceptable answers and will be passed off by a designated staff member. Day 3 is all about what the student will commit to do upon being released from Stabilization. Commitments must be specific and measurable, so that staff can hold the patient accountable for them. This paper will be given to the patient’s coaches upon release. I Will Commit to Improve Myself 1) I need to set goals to treat my peers better, I will commit to treat my peers better in at least the following 3 ways: _______________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 2) I also need to set goals to respect staff better, I will commit to respect staff better in at least the following 3 ways: _______________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 3) My behavior on the cottage must improve, I will commit to be a better cottage member in at least the following 3 ways:__________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 4) What are some things that I learned from being in stabilization that can help me to be a better person (ex. “I learned that stealing from others is wrong, so I won’t do it again”, “I learned that getting upset over small things doesn’t help me be a good person”)? _____________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
- 4. Student Name: Date: Staff Signature___________________________ Student Signature________________________________ Stabilization Release Worksheet-‐ Same-‐Day Release Sheet General Instructions: This sheet must be completed in order to be released from stabilization. If patients refuse, 1 new sheet will be provided every hour until completed. Patients cannot receive drawing paper, a book, or other activities until the sheet is completed. Instructions for Same-‐Day Release Sheet: All questions/sections must be answered completely by the patient. Thoughtful answers are the only acceptable answers and will be passed off by a designated staff member. If any answers contain phrases that blame other peers or staff, the answers will not be accepted and the patient must try again in an hour. This paper will be given to the patient’s coaches upon release. I Am Responsible For My Actions and Feelings 1) If I am truly honest about being responsible for my actions, I must ask myself questions like: Did I choose to get upset about something a peer said? Did I assault a peer or staff? Did I get out of control with my language and interactions with others? Did I choose to self-‐harm to the point that staff had to stop me? Was I becoming a danger to myself or others in any way? Student must provide at least 3 sentences describing his feelings and actions that led to him being in stabilization. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ I Could Have Controlled My Actions and Feelings Better 1) In general, what could I have done differently in that situation instead of getting so upset? Student must provide at least 3 sentences describing what he could have done differently. ____________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ I Will Commit to Improve Myself 1) My behavior on the cottage/school must improve, I will commit to be a better cottage/school member in at least the following 3 ways: ________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________