DSHS Form 10-442 "Goal Setting and Action Planning Worksheet" - Washington

What Is DSHS Form 10-442?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2015;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 10-442 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 10-442 "Goal Setting and Action Planning Worksheet" - Washington

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HEALTH HOME
Goal Setting and Action Planning Worksheet
NAME
DATE
Long Term Goal
Short Term Goal
Describe something you will do now to improve your health.
Describe what you will do
1. What you’ll do:
2. Where you’ll do it:
3. The number of times each day / week:
4. How long will you commit to doing this:
Possible barriers to your success:
Plan to overcome the barriers:
Conviction
How important is it for you to work on the goal you identified above? Check the box which best shows your response.
Not at all convinced
1
2
3
4
5
6
7
8
9
10
Totally convinced
Confidence
How confident are you that you will be successful in reaching the goal you identified above?
Check the box which best shows your response.
Not at all confident
1
2
3
4
5
6
7
8
9
10
Totally confident
Readiness
How ready are you to work on the goal you identified above? Check the box which best shows your response.
Not at all ready:
1
2
3
4
5
6
7
8
9
10
Totally ready
Plan for follow-up:
HEALTH HOME GOAL SETTING AND ACTION PLANNING WORKSHEET
DSHS 10-442 (REV. 02/2015)
HEALTH HOME
Goal Setting and Action Planning Worksheet
NAME
DATE
Long Term Goal
Short Term Goal
Describe something you will do now to improve your health.
Describe what you will do
1. What you’ll do:
2. Where you’ll do it:
3. The number of times each day / week:
4. How long will you commit to doing this:
Possible barriers to your success:
Plan to overcome the barriers:
Conviction
How important is it for you to work on the goal you identified above? Check the box which best shows your response.
Not at all convinced
1
2
3
4
5
6
7
8
9
10
Totally convinced
Confidence
How confident are you that you will be successful in reaching the goal you identified above?
Check the box which best shows your response.
Not at all confident
1
2
3
4
5
6
7
8
9
10
Totally confident
Readiness
How ready are you to work on the goal you identified above? Check the box which best shows your response.
Not at all ready:
1
2
3
4
5
6
7
8
9
10
Totally ready
Plan for follow-up:
HEALTH HOME GOAL SETTING AND ACTION PLANNING WORKSHEET
DSHS 10-442 (REV. 02/2015)