1. (specify behavior you want to change)
Name: ___________________
Behavior Change Contract Once you have chosen a behavior you wish to change and have identified ways to change it, your next step is to sign a behavior change contract. Your contract should show your commitment to changing your behavior and include details of your program.
I ___________________________________ agree to __________________________________________ _____________________________________________________________________________________ I will begin on __________________ and plan to reach my goal of _______________________________ _____________________________________________________________________________________ by _____________________. In order to reach my final goal, I have devised the following schedule of mini-goals. For each step in my program, I will give myself the reward listed. _______________________________________ _________________ _______________________ _______________________________________ _________________ _______________________ _______________________________________ _________________ _______________________ My overall reward for reaching my final goal will be ________________________________ I have gathered and analyzed data on my target behavior and have identified the following strategies for changing my behavior: ______________________________________________________________________ _________________________________________________________________________________________I will use the following tools to monitor my progress toward reaching my final goal: __________________________________________________________________________________________________________________________________________________________________________________ I sign this contract as an indication of my personal commitment to reach my goal. _____________________________________________________ ______________________________ I have recruited a helper who will witness my contract and _________________________________________ _________________________________________________________________________________________ _____________________________________________________ ______________________________
(name)
(specify behavior you want to change)
(start date)
(specify final goal)
(final target date)
(minigoal 1) (target date) (reward)
(minigoal 1) (target date) (reward)
(minigoal 1) (target date) (reward)
(list any charts, graphs, or journals you plan to use)
(your signature) (date)
(witness’s signature) (date)
Insel/Roth, Connect Core Concepts in Health, Eleventh Edition © 2010 The McGraw-Hill Companies, Inc. Chapter 1