Name ________________________

What aspect of your health do you wish to change?  (Specific description of a health related behavior must be given.)
 
 
 

What are your short, medium and long term goals?  (Measurable & Realistic)
 
 
 
 

What is your current baseline for this behavior?  (Where are you right now?)
 
 

Benefits you anticipate as a result of this change?
 
 

If you have tried to change this behavior before why were you not successful?
 
 

Why will it be different this time?
 
 

What will happen if you don’t change this behavior?
 
 

What are some antecedents of your current behavior patterns? (Triggers)
 
 
 
 

Identify at least three factors that will assist you in reaching your goals. (Reinforcing, Enabling, and Predisposing Factors)

1.
 

2.
 

3.
 

List at least three obstacles to the successful achievement of your behavior change.

1.
 

2.
 

3.
 

What specifically will you do to address these barriers?
 
 
 
 

Describe your short, medium, and long term rewards. (Must be desirable, attainable, extrinsic, and you must be willing to forgo the reward if not successful.)
 

I  ___________________________________ agree to

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

from __________________to________________.
 

If I complete the  above goal I will reward myself with _____________________

__________________________________________________________________,

however, if I am not successful I agree to forgo the above reward.
 
 
 

Signed _______________________________    date _______
 
 

Witness ______________________________   date _______
 

Witness ______________________________    date _______
 

Witness ______________________________    date _______