Change Plan
Student Name:
Instructions:
· Use this template to document your results from the How Do I Plan to Change? section of the Change Planner.
· Delete the <bracketed instructional text> from the document before submitting it to your instructor.
Wellness Area: Tobacco
What’s Your Readiness Stage in the Area of Tobacco?
<Pre-contemplation, Contemplation, Preparation, Action, Maintenance, or Termination>
My Self-Reflection Revelations: Summarized
<Summarize your self-reflection revelations here
· What kind of an environment were you in when you used tobacco?
· Was there any event that triggered the tobacco use?
· Were you able to say "No" when tempted to use tobacco?
My Behavioral Change Contract
Enter your "My Behavioral Change Contract" results below
1. I, _____, have decided to engage in a Behavior Change for use of Tobacco.
2. My Goal:
<Enter your goals for the wellness area here>
3. The Objective(s) for my indicated Goal is/are:
<Enter your objective/s for the goal here>
4. I believe the following Enabling Factors will help me accomplish my Goal:
5. I believe the following Reinforcing Factors will help me accomplish my Goal:
6. I believe the following Obstacles might prevent me from achieving my Goal:
7. If I accomplish my Goal, I will reward myself with:
8. Timeline:
Summarize your plans to improve behaviors in this wellness area
<Answer the following questions when summarizing your plans:
What is your current behavior in this wellness area?
What would you like to change about yourself in this wellness area?
Have you previously made a similar plan that could not be followed for some reason? If yes, then identify when and under what circumstances you discontinued the plan?
How optimistic are you about this plan? Is it achievable?>
Wellness Area: Drugs and Alcohol
What’s Your Readiness Stage in the Area of Drugs and Alcohol?
<Pre-contemplation, Contemplation, Preparation, Action, Maintenance, or Termination>
My Self-Reflection Revelations: Summarized
<Summarize your self-reflection revelations here
· What kind of an environment were you in when you last took drugs or drank alcohol?
· Was there any event that triggered your behavior?
· Were you able to say "No" when tempted with drugs and/or alcohol?
My Behavioral Change Contract
<Enter your “My Behavioral Change Contract” results below>
1. I, _____, have decided to engage in a Drugs and Alcohol Behavior Change.
2. My Goal:
<Enter your goals for the wellness area here>
3. The Objective(s) for my indicated Goal is/are:
<Enter your objective/s for the goal here>
4. I believe the following Enabling Factors will help me accomplish my Goal:
5. I believe the following Reinforcing Factors will help me accomplish my Goal:
6. I believe the following Obstacles might prevent me from achieving my Goal:
7. If I accomplish my Goal, I will reward myself with:
8. Timeline:
Summarize your plans to improve behaviors in this wellness area
<Answer the following questions when summarizing your plans:
What is your current behavior in this wellness area?
What would you like to change about yourself in this wellness area?
Have you previously made a similar plan that could not be followed for some reason? If yes, then identify when and under what circumstances you discontinued the plan?
How optimistic are you about this plan? Is it achievable?>
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