Worksheet
Self Advocacy Self-Assessment
Part 1: Confidence and Coping Scales
- How confident are you in asking for help when you feel stuck?1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐
(1 = Not at all, 5 = Very confident)Why did you choose this number?
- How often do you use a coping strategy (like deep breathing or taking a break) when you feel upset?1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐
(1 = Rarely, 5 = Always)What strategy do you use most often? Why?
- How comfortable do you feel telling your teacher when you’re overwhelmed?1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐
(1 = Not at all, 5 = Very comfortable)Explain your choice:
Part 2: Reflection on a Recent Experience
Think about a time in class when you felt stuck, upset, or overwhelmed. Answer the questions below.
- What happened? Describe the situation:
- How did you feel? (e.g., frustrated, sad, confused)
- What did you do in that moment?
- Did you ask for help or use a coping strategy? Why or why not?
Part 3: Planning and Goal Setting
- One person you can ask for support next time you feel stuck is:
- Three coping strategies you want to try or practice:
a. ____________________________________________
b. ____________________________________________
c. ____________________________________________ - My personal advocacy plan: Write out what you will say or do the next time you need help.
Keep this assessment somewhere you can see it. Use it to remind yourself of your strengths and your plan whenever you need a boost of confidence!
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Rubric
Self-Advocacy Self-Assessment Rubric
Use this rubric to evaluate the student’s completed work on the Self Advocacy Self-Assessment. Circle or highlight the performance level for each criterion and total the points at the bottom.
Scoring Scale (per criterion):
4 = Exemplary | 3 = Proficient | 2 = Emerging | 1 = Beginning
| Criterion | 1 – Beginning | 2 – Emerging | 3 – Proficient | 4 – Exemplary | Points Possible |
|---|---|---|---|---|---|
| 1. Reflection Depth | Answers are minimal or off-topic. Little evidence of personal insight. | Some attempt to describe feelings or events, but details are vague or incomplete. | Thoughtful description of situation and emotions with clear personal insight. | Rich, detailed reflection showing deep awareness of triggers, feelings, and thought processes. | 4 |
| 2. Coping Strategy Identification | No strategies named or strategies are impractical. | Names one strategy but gives little explanation or shows limited understanding. | Identifies one or two realistic strategies and explains why they are helpful. | Identifies multiple meaningful strategies, explaining how and when each will be used. | 4 |
| 3. Goal-Setting & Plan Specificity | Plan is missing or too general to act on (e.g., “I’ll try harder”). | Plan includes one step but lacks details on who, when, or how. | Plan states clear steps, who to ask for help, and examples of when to use a strategy. | Plan is highly specific: exact wording, timing, people involved, and backup options are included. | 4 |
| 4. Clarity & Organization | Responses are hard to follow; writing is disorganized or incomplete. | Some sections are clear, but others are confusing or partially left blank. | Most responses are well-organized, legible, and complete with minimal gaps. | All sections are thoroughly completed, neatly organized, and easy to understand. | 4 |
Total Points: _____ / 16
Performance Levels:
• 14–16 = Exemplary (Consistently demonstrates strong self-advocacy skills)
• 10–13 = Proficient (Meets expectations with minor areas to strengthen)
• 6–9 = Emerging (Developing skills; needs more practice and support)
• 1–5 = Beginning (Requires significant guidance to build self-advocacy habits)
Suggestions for Next Steps:
- Review areas scored 1–2 and coach the student on adding detail or examples.
- Model additional coping strategies and role-play how to ask for help.
- Set a check-in goal: revisit this rubric in two weeks to measure growth.