Worksheet 5

	Behavior Change Contract

Once you have chosen a behavior you wish to change and have identified ways to change it (see Wellness Worksheet 4), 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. Print out the contract shown below, or devise one that more closely fits your goals and your program.


(1)	I ______________________________________________________________	agree to	_______________________________________________________________________
	(name)		(specify behavior you want to change)
	___________________________________________________________________________________________________________________________________________________

	___________________________________________________________________________________________________________________________________________________

(2)	I will begin on	____________________________________________	and plan to reach my goal of	_________________________________________________________
		(start date)		(specify final goal)
	___________________________________________________________________________________________________________________________________________________

	by	________________________________________________.
		(final target date)

(3)	In order to reach my final goal, I have devised the following schedule of minigoals. For each step in my program, I will give myself the reward listed.
	_________________________________________________________	____________________________________________	______________________________________________
	(minigoal 1)	(target date)	(reward)
	_________________________________________________________	____________________________________________	______________________________________________
	(minigoal 2)	(target date)	(reward)
	_________________________________________________________	____________________________________________	______________________________________________
	(minigoal 3)	(target date)	(reward)

(4)	I have gathered and analyzed data on my target behavior and have identified the following strategies for changing my behavior: ________________________________________________

	___________________________________________________________________________________________________________________________________________________

	___________________________________________________________________________________________________________________________________________________

(5)	I will use the following tools to monitor my progress toward reaching my final goal:

	___________________________________________________________________________________________________________________________________________________
	(list any charts, graphs, or journals you plan to use)
	___________________________________________________________________________________________________________________________________________________

	I sign this contract as an indication of my personal commitment to reach my goal.

	___________________________________________________________________________________	________________________________________________________________
	(your signature)	(date)

	I have recruited a helper who will witness my contract and _____________________________________________________________________________________________________

	___________________________________________________________________________________________________________________________________________________
	(list any ways in which your helper will participate in your program)
	___________________________________________________________________________________	________________________________________________________________
	(witness's signature)	(date)

Describe any special strategies you will use to help change your behavior.

Create a plan below for any type of chart, graph, or journal you will use to monitor your progress.

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