How will I reach my goal? What steps do I need to take?
1.
2.
3.
4.
5.
What materials and support do I need to reach my goal?
1.
2.
3.
Name Grade Date
Use this worksheet to create a step-by-step plan to meet a goal and review the outcome.
What do I want to accomplish? Why?
NoYes
PREDICTION: How long will it take for me to
reach my goal?
Will I need a Plan B?
How long did it take for me to reach my goal?
How much did I get done? Did I get it done on me?
What worked?
What will I try dierently next me (Plan B)?
Note. From “Cognive Rehabilitaon: Execuve Funcons,” by M. Yivisaker, S. Szekeres, and T. Feeney, in Traumac brain injury rehabilitaon: Children and
adolescents (2nd ed., p. 244), by M. Yivisaker (Ed.), 1998. Buerworth-Heinemann. Copyright ©1998 by Buerworth-Heinemann. Adapted with permission.
Plan complete
How will I reach my goal? What steps do I need to take?
1.
2.
3.
4.
5.
What materials and support do I need to reach my goal?
1.
2.
3.
Name Grade Date
Use this worksheet to create a step-by-step plan to meet a goal and review the outcome.
What do I want to accomplish? Why?
NoYes
PREDICTION: How long will it take for me to
reach my goal?
Will I need a Plan B?
Get all ready for school fast each morning so dad can cook a nice
breakfast and we can eat and watch a show before school.
Make a list of all the things we have to do to be ready for
school.
Put the list of things to do in the best order
Dekrate the list for fun
In the morning, dad gives us our list and we follow it and he
maks breakfast
When we are washed up, dresed, beds made, backpacks ready
and at the door, watch show and eat creps!
Paper for lists
Markers, stikers, glitter to dekrate the list
20 minits to be reddy for school and 30
minits to watch a show and eat breakfast
Rozy and Toria
3rd and 1st
Saturday
How long did it take for me to reach my goal?
How much did I get done? Did I get it done on me?
What worked?
What will I try dierently next me (Plan B)?
Note. From “Cognive Rehabilitaon: Execuve Funcons,” by M. Yivisaker, S. Szekeres, and T. Feeney, in Traumac brain injury rehabilitaon: Children and
adolescents (2nd ed., p. 244), by M. Yivisaker (Ed.), 1998. Buerworth-Heinemann. Copyright ©1998 by Buerworth-Heinemann. Adapted with permission.
Plan complete
30 minits to be reddy for school and 20 minits to watch a show and
eat breakfast
We got everthing done fast and had a great breakfast and
watched our favrite show.
It was great! Dad was happy that he had time to cook and he
didn’t get upset about being late for work agen.
We wouldn’t change things.
How will I reach my goal? What steps do I need to take?
1.
2.
3.
4.
5.
What materials and support do I need to reach my goal?
1.
2.
3.
Name Grade Date
Use this worksheet to create a step-by-step plan to meet a goal and review the outcome.
What do I want to accomplish? Why?
NoYes
PREDICTION: How long will it take for me to
reach my goal?
Will I need a Plan B?
Clean our room. We are not alowed to go play until the room is clean.
Go to store and get boxes that fit under the bed
Put Toys in boxes: one for dolls, one for doll things, and one
for doll cloths
Dekrate the boxes with stickers, and other fun things
Put boxes under beds
Make beds.
Boxes
Stick on labels
Art stuff (markers, stickers, glitter)
2 hours for trip to store and lunch + 2
hours to play and put toys in boxes
Rozy and Toria
3rd and 1st
Saturday
How long did it take for me to reach my goal?
How much did I get done? Did I get it done on me?
What worked?
What will I try dierently next me (Plan B)?
Note. From “Cognive Rehabilitaon: Execuve Funcons,” by M. Yivisaker, S. Szekeres, and T. Feeney, in Traumac brain injury rehabilitaon: Children and
adolescents (2nd ed., p. 244), by M. Yivisaker (Ed.), 1998. Buerworth-Heinemann. Copyright ©1998 by Buerworth-Heinemann. Adapted with permission.
Plan complete
3 hours
We cleaned the room. We likd playing with all of the dolls and Toys
so it took longer but it was fun so it was okay.
The boxes were fun to dekirate and made it easy to sort things
and make the room look neat.
It worked good. We wouldn’t change things.
How will I reach my goal? What steps do I need to take?
1.
2.
3.
4.
5.
What materials and support do I need to reach my goal?
1.
2.
3.
Name Grade Date
Use this worksheet to create a step-by-step plan to meet a goal and review the outcome.
What do I want to accomplish? Why?
NoYes
PREDICTION: How long will it take for me to
reach my goal?
Will I need a Plan B?
Jamar Selmon 6th 09/10/2021
I want to have more friends. My best friend moved away over the summer and most of my friends from
elementary school go to a dierent middle school than me.
There are a bunch of nice kids in my class who play games together online. One of them asked me
to play someme. I think I could ask one of them to hang out aer school.
The teacher reminded us of the aer school clubs and told us we could start are own club if we
nd at least one other person to join. I might start a sh club since I have a saltwater aquarium.
I am prey good at chess so will start with checking out the chess club, then maybe try to ski club
this winter.
I missed cross country this fall but will try out for track this spring.
Once I make some friends, I will ask my parents if I could have some kids over for a bonre and
sleepover.
I need to talk my parents into a new PS4 and some credits so I can get some cool skins for gaming.
Courage. Talking to new people makes me nervous and what if they laugh at me
The clubs cost money so will ask my parents to help by giving me some money.
? I have no idea but hopefully not
long
How long did it take for me to reach my goal?
How much did I get done? Did I get it done on me?
What worked?
What will I try dierently next me (Plan B)?
Note. From “Cognive Rehabilitaon: Execuve Funcons,” by M. Yivisaker, S. Szekeres, and T. Feeney, in Traumac brain injury rehabilitaon: Children and
adolescents (2nd ed., p. 244), by M. Yivisaker (Ed.), 1998. Buerworth-Heinemann. Copyright ©1998 by Buerworth-Heinemann. Adapted with permission.
Plan complete
3 weeks
It worked. I made two new friends that came over to my house and was invited to a birthday party for a kid
in my gaming group.
Trying new things and pung myself out there
I’m geng the laser cannon so I can beat Jusn next me we game
How will I reach my goal? What steps do I need to take?
1.
2.
3.
4.
5.
What materials and support do I need to reach my goal?
1.
2.
3.
Name Grade Date
Use this worksheet to create a step-by-step plan to meet a goal and review the outcome.
What do I want to accomplish? Why?
NoYes
PREDICTION: How long will it take for me to
reach my goal?
Will I need a Plan B?
Caleb Gray 7th 04/13/2021
Finish today’s 3 homework assignments. Keep my grades up so Dad will let me go dirt-biking this weekend.
Write down my assignments. 1. Math problems (20 min) 2. Social Studies Ch. + Qs (20 min +10
min) 3. Art project—sketch chair (15 min)
Break them down into steps
Guess amount of me to nish each one
Put in backpack when nished (so I don’t forget it)
Do in quiet room, no TV or sister to distract me
Need math book, social studies book + paper, sketch pad, pencil
Timer on phone
65 min
How long did it take for me to reach my goal?
How much did I get done? Did I get it done on me?
What worked?
What will I try dierently next me (Plan B)?
Note. From “Cognive Rehabilitaon: Execuve Funcons,” by M. Yivisaker, S. Szekeres, and T. Feeney, in Traumac brain injury rehabilitaon: Children and
adolescents (2nd ed., p. 244), by M. Yivisaker (Ed.), 1998. Buerworth-Heinemann. Copyright ©1998 by Buerworth-Heinemann. Adapted with permission.
Plan complete
(75 min) Math—18 min. SS—read 25 min. Q’s—17
min. Art—15 min.
Got it all done but it took longer
Being in quiet room helped, away from distracons. Timer helped me to stay on track, but it also made me
nervous.
Maybe do art project in between Math + SS—my brain hurt aer doing both. Give myself more me.
How will I reach my goal? What steps do I need to take?
1.
2.
3.
4.
5.
What materials and support do I need to reach my goal?
1.
2.
3.
Name Grade Date
Use this worksheet to create a step-by-step plan to meet a goal and review the outcome.
What do I want to accomplish? Why?
NoYes
PREDICTION: How long will it take for me to
reach my goal?
Will I need a Plan B?
Jonathan Schwartz 7th 09/05/2021
I would like to make the 7th Grade boys basketball team. I want to do this because I love basketball and
think it would be a good way to spend me with my friends who are also trying out for the team.
Get parent permission form signed and sign up for the tryouts.
I need to improve my free throw shoong.
I need to improve my defensive skills and rebounding.
I need to improve my jump shot.
I need to get into beer shape
Ask parents for a rebounding bounce back net so I can get more shoong in when I pracce
I need to shoot at least 50 free throws a day
I need to start running (long distance and sprints) My goal is to be able to run 2 miles in 12 min-
utes and increase my sprinng speed.
60 minutes a day at least 6 days a
week
How long did it take for me to reach my goal?
How much did I get done? Did I get it done on me?
What worked?
What will I try dierently next me (Plan B)?
Note. From “Cognive Rehabilitaon: Execuve Funcons,” by M. Yivisaker, S. Szekeres, and T. Feeney, in Traumac brain injury rehabilitaon: Children and
adolescents (2nd ed., p. 244), by M. Yivisaker (Ed.), 1998. Buerworth-Heinemann. Copyright ©1998 by Buerworth-Heinemann. Adapted with permission.
Plan complete
as expected
I was able to make my goal about 90% of the me but somemes I had to do my homework instead. :(
I made the team. Now I want to be a starter!
Pracce my 3 point shot :)
How will I reach my goal? What steps do I need to take?
1.
2.
3.
4.
5.
What materials and support do I need to reach my goal?
1.
2.
3.
Name Grade Date
Use this worksheet to create a step-by-step plan to meet a goal and review the outcome.
What do I want to accomplish? Why?
NoYes
PREDICTION: How long will it take for me to
reach my goal?
Will I need a Plan B?
Addison Brown 10th 10/27/2021
I want to get a 90% or higher on my Geometry nal next week. I didn’t do well on the last test and need an
A on this one to get a B for my overall rst quarter grade.
I need to study for at least 30 minutes every day unl the exam
I will go to my teacher’s classroom at least twice to work on pracce items for the test
I will go to the teacher’s test review session the day before the exam
I will use my study hall me to go to the math lab at least twice to work with the student mentors.
Dedicaon because I really don’t like geometry at all
Extra pracce items from the teacher
Condence that I can do this stu :)
7-8 hours
How long did it take for me to reach my goal?
How much did I get done? Did I get it done on me?
What worked?
What will I try dierently next me (Plan B)?
Note. From “Cognive Rehabilitaon: Execuve Funcons,” by M. Yivisaker, S. Szekeres, and T. Feeney, in Traumac brain injury rehabilitaon: Children and
adolescents (2nd ed., p. 244), by M. Yivisaker (Ed.), 1998. Buerworth-Heinemann. Copyright ©1998 by Buerworth-Heinemann. Adapted with permission.
Plan complete
7 hours
I missed going to one of the math labs because I had to nish an English paper
What worked? The plan worked. I got a 89 on the test and the teacher curved it up to an 92. I can’t believe
Allison got a 97! :(
I was prey happy with the results. I just need to remember what it took to do well this me.
