Impacter PathwayBH Screener · Grades 3–12

Planning Sheet

Name
Grade
School
Teacher
Student email or ID
Period
Date
How I'm answering:I'll record my answersThis paper is my answer (I wrote full sentences)
1
What's something you're better at now than you used to be? And, what do you think helped you get there?
The momentWho was there? Where? When?
What I did and feltWhat happened? What went on inside?
What helped / what I learnedWhat would you tell a friend?
2
Tell me about a time you noticed how someone else was feeling. What helped you notice, and what did you do?
The momentWho was there? Where? When?
What I did and feltWhat happened? What went on inside?
What helped / what I learnedWhat would you tell a friend?
3
Tell me about a time something felt really hard, but you kept trying. What did you do to get through it, and what helped you keep going?
The momentWho was there? Where? When?
What I did and feltWhat happened? What went on inside?
What helped / what I learnedWhat would you tell a friend?
These are notes, not a script. When you record, talk it through in your own words.Page 1 / 2
Impacter PathwayBH Screener · Grades 3–12
Name
Teacher
Period
4
Tell me about a moment when you paused before acting. What were you about to do, what did that feeling inside you tell you, and what did you choose to do next?
The momentWho was there? Where? When?
What I did and feltWhat happened? What went on inside?
What helped / what I learnedWhat would you tell a friend?
5
Tell me about a time someone’s feelings were hurt and you tried to help. What did you do to make things better?
The momentWho was there? Where? When?
What I did and feltWhat happened? What went on inside?
What helped / what I learnedWhat would you tell a friend?
6
Tell me about a time you were curious about something and wanted to figure it out. What did you do to get help and learn more?
The momentWho was there? Where? When?
What I did and feltWhat happened? What went on inside?
What helped / what I learnedWhat would you tell a friend?
These are notes, not a script. When you record, talk it through in your own words.Page 2 / 2