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Worksheet No. 5

(1) This document provides a behavior change contract template for clients to commit to changing a specific behavior. (2) The contract includes setting a start date and final goal date, as well as establishing mini-goals and rewards along the way. (3) Clients identify strategies for changing their behavior and tools for monitoring their progress, and sign the contract with a witness to affirm their commitment.

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Xie Zhen Wu
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183 views

Worksheet No. 5

(1) This document provides a behavior change contract template for clients to commit to changing a specific behavior. (2) The contract includes setting a start date and final goal date, as well as establishing mini-goals and rewards along the way. (3) Clients identify strategies for changing their behavior and tools for monitoring their progress, and sign the contract with a witness to affirm their commitment.

Uploaded by

Xie Zhen Wu
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Name _________________________ Section ________________ Date __________________

W E L L N E S S WO R K S H E E T 5
Client Behavior Change Contract

After you've chosen a behavior to change and have identified ways to change it (see Wellness Worksheet 4),
your next step is to formulate a behavior change contract. Your contract should show commitment to changing
behaviors and include details of your program. Use 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.
_____________________________________________ _____________ ___________________
(sub goal 1) (target date) (reward)
_____________________________________________ _____________ ___________________
(sub goal 2) (target date) (reward)
_____________________________________________ _____________ ___________________
(sub goal 3) (target date) (reward)

My overall reward for reaching my final goal will be ________________________________________.


(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 attesting to my personal commitment to reach my goal.
_______________________________________________________ __________________________
(your signature) (date)

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


___________________________________________________________________________________.
(list any way in which your coach will participate in your program)
_______________________________________________________ __________________________
(witness’s signature) (date)
WELLNESS WORKSHEET 5 — continued

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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