"Behavior Change Contract Template"

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Name: ______________________________________________________________________________________ Date: _________________________________
Instructor: ____________________________________________________________________________________ Section: _______________________________
B E H AV I O R C H A N G E C O N T R A C T
Complete the Assess Yourself questionnaire. After reviewing your results and considering the various factors
that influence your decisions, 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:
My long-term goal for this behavior change is:
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):
1.
2.
3.
The strategies I will use to overcome these obstacles are:
1.
2.
3.
Resources I will use to help me change this behavior include:
a friend/partner/relative:
a school-based resource:
a community-based resource:
a book or reputable website:
In order to make my goal more attainable, I have devised these short-term goals:
short-term goal
target date
reward
short-term goal
target date
reward
short-term goal
target date
reward
When I make the long-term behavior change described above, my reward will be:
target date:
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:
Name: ______________________________________________________________________________________ Date: _________________________________
Instructor: ____________________________________________________________________________________ Section: _______________________________
B E H AV I O R C H A N G E C O N T R A C T
Complete the Assess Yourself questionnaire. After reviewing your results and considering the various factors
that influence your decisions, 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:
My long-term goal for this behavior change is:
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):
1.
2.
3.
The strategies I will use to overcome these obstacles are:
1.
2.
3.
Resources I will use to help me change this behavior include:
a friend/partner/relative:
a school-based resource:
a community-based resource:
a book or reputable website:
In order to make my goal more attainable, I have devised these short-term goals:
short-term goal
target date
reward
short-term goal
target date
reward
short-term goal
target date
reward
When I make the long-term behavior change described above, my reward will be:
target date:
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:
B E H AV I O R C H A N G E C O N T R A C T
Complete the Assess Yourself questionnaire. After reviewing your results and considering the various factors
that influence your decisions, 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:
My long-term goal for this behavior change is:
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):
1.
2.
3.
The strategies I will use to overcome these obstacles are:
1.
2.
3.
Resources I will use to help me change this behavior include:
a friend/partner/relative:
a school-based resource:
a community-based resource:
a book or reputable website:
In order to make my goal more attainable, I have devised these short-term goals:
short-term goal
target date
reward
short-term goal
target date
reward
short-term goal
target date
reward
When I make the long-term behavior change described above, my reward will be:
target date:
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:
To submit the completed worksheet, save it to your computer and email it to
your instructor or upload it to their digital dropbox as directed.
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