1_behavior_change_contract-1.doc

Behavior Change Contract Place your cursor in gray boxes to fill out worksheet. Remember to save your answers. Name: FORMTEXT ????? Date: FORMTEXT ????? Choose a health behavior that you would like to change, starting this quarter or semester. Sign the contract at the bottom to affirm your commitment to making a healthy change and ask a friend to witness it. My behavior change will be: FORMTEXT ????? My long-term goal for this behavior change is: FORMTEXT ????? These are three obstacles to change (things that I am currently doing or situations that contribute to this behavior or make it harder to change): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? The strategies I will use to overcome these obstacles are: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Resources I will use to help me change this behavior include: a friend/partner/relative: FORMTEXT ????? a school-based resource: FORMTEXT ????? a community-based resource: FORMTEXT ????? a book or reputable website: FORMTEXT ????? In order to make my goal more attainable, I have devised these short-term goals. short-term goal FORMTEXT ????? target date FORMTEXT ????? reward FORMTEXT ????? short-term goal FORMTEXT ????? target date FORMTEXT ????? reward FORMTEXT ????? short-term goal FORMTEXT ????? target date FORMTEXT ????? reward FORMTEXT ????? When I make the long-term behavior change described above, my reward will be: FORMTEXT ????? target date FORMTEXT ????? I intend to make the behavior change described above. I will use the strategies and rewards to achieve the goals that will contribute to a healthy behavior change. Signed: _____________________________ Witness:_____________________________ Copyright © 2009 Pearson Education Inc. PAGE 1