Perception Checking Communication Worksheet Form
Use this form to document a specific interaction, your interpretation of another person's message or behavior, and your perception-checking response. The Perception Checking Communication Worksheet Form guides you through each step.
Date of Interaction
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Name
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First Name
Last Name
Name of the Other Person Involved
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Briefly describe the situation or context of the interaction.
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What did the other person say or do?
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What was your interpretation of their message or behavior?
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List at least one alternative interpretation of their message or behavior.
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What feelings did you experience during this interaction?
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How did you (or would you) check your perception with the other person? Write your perception-checking response.
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What did you learn from this exercise or what would you do differently next time?
Submit Worksheet
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