Emotion Regulation Self-Assessment Worksheet

Student Name: ____________________________ Date: _______________

1. Self-Rating

1. On a scale of 1 (I get upset easily) to 5 (I stay calm most of the time), how would you rate yourself when something bothers you? ________
   
   
   
2. How often do you feel that you lose control of your emotions? (Circle one)Explain why you chose this answer:
   
   
   
   
   
   
   • Never
   • Rarely
   • Sometimes
   • Often
   • Always

2. Identifying Triggers

1. Think of a recent time when you felt very upset. What happened?
   
   
   
   
   
   
   
   
   
   
   
   
2. What emotions did you feel in that moment? (List at least three)
   
   
   
   
   
   
3. What are your top three triggers—the situations or events that most often make you upset?
   a. _________________________
   b. _________________________
   c. _________________________
   
   

3. Current Reactions

1. When you feel upset, what do you usually do? (Check all that apply and briefly describe)
   • Yell or scream: __________________________
     
     
   • Cry: __________________________
     
     
   • Withdraw (avoid people): __________________________
     
     
   • Other: __________________________
     
     
2. How effective do you think these reactions are at helping you feel better? (1 = Not effective, 5 = Very effective) ________
   
   
   

4. Coping Strategies

1. List the strategies you have tried in the past to calm down instead of yelling or screaming.
   • Strategy 1: __________________________
     
     
   • Strategy 2: __________________________
     
     
   • Strategy 3: __________________________
     
     
2. Which one of these strategies helped you the most? Why?
   
   
   
   
   
   
3. What new strategies would you like to try? (Hint: You can use the Coping Strategies Cards for ideas.)
   
   
   
   
   
   
   
   

5. Reflection

1. In one or two sentences, why is it important to find ways to calm down without yelling or screaming?
   
   
   
   
   
   
   
   
   
   

Personalized Emotion Regulation Plan Template

Student Name: ____________________________ Date: _______________

1. My Triggers

List your top three situations or events that make you most upset:

1. ____________________________
   
   
   
2. ____________________________
   
   
   
3. ____________________________
   
   
   

2. My Goal

What do you want to achieve with this plan? (Be as specific as possible.)

3. My New Strategies

Choose three ideas from the Coping Strategies Cards or your own list.

• Strategy A: ____________________________
  
  
  
  
• Strategy B: ____________________________
  
  
  
  
• Strategy C: ____________________________
  
  
  
  

4. Implementation Steps

For each strategy, write three clear steps you will follow when you notice a trigger.

Strategy A: ____________________________

1. ________________________________________
   
   
   
   
2. ________________________________________
   
   
   
   
3. ________________________________________
   
   
   
   

Strategy B: ____________________________

1. ________________________________________
   
   
   
   
2. ________________________________________
   
   
   
   
3. ________________________________________
   
   
   
   

Strategy C: ____________________________

1. ________________________________________
   
   
   
   
2. ________________________________________
   
   
   
   
3. ________________________________________
   
   
   
   

5. Reminders & Practice Goal

How will you remind yourself to use this plan? (For example, note on your desk, alarm on your phone, card in your pocket.)

My practice goal before our next session (e.g., use at least one strategy three times):

6. Reflection After Using Your Plan

After you try your plan, answer these questions:

1. Did I use my plan when I felt upset? (Yes / No)
   
   
   
   
2. Which strategy worked best and why?
   
   
   
   
   
   
3. What could I change or improve next time?
   
   
   
   
   
   

Coping Strategies Cards

Cut these cards out and keep them handy. When you feel upset, pick one strategy and practice it until you feel calmer.

1. Deep Breathing
   • Inhale slowly for 4 counts, hold for 2 counts, exhale for 4 counts. Repeat 5 times.
   
   
2. Count to 10
   • Slowly count backward from 10 to 1. Focus on each number and your breathing.
   
   
3. Positive Self-Talk
   • Repeat a calming phrase like “I can handle this” or “I am in control.”
   
   
4. Take a Walk
   • Step outside or move around the room. Notice how your body feels as you move.
   
   
5. Progressive Muscle Relaxation
   • Tense each muscle group for 5 seconds (toes, legs, arms, shoulders), then release slowly.
   
   
6. Visualization
   • Close your eyes and imagine a peaceful place (beach, forest). Use all five senses in your mind.
   
   
7. Squeeze a Stress Ball
   • Grip and release a soft ball or rolled sock for 10–15 seconds to let tension go.
   
   
8. Listen to Music
   • Put on a favorite song and focus on the rhythm, melody, and lyrics.
   
   
9. Write or Draw
   • Jot down your feelings in a journal or sketch how you feel on paper.
   
   
10. Drink Water
    • Slowly sip a glass of cool water. Notice the taste, temperature, and movement.
    
    
11. Talk to a Friend or Adult
    • Share how you feel with someone you trust. Let them listen without judgment.
    
    
12. 3 Shoulder Rolls
    • Slowly roll your shoulders forward and backward three times to release tension.