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:
________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________