Behavior Change Contract printable pdf download

Behavior Change Contract

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):

The strategies I will use to overcome these obstacles are:

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:

Behavior Change Contract