Behavior Change Contract
Name: ______________________________
Date: _______________
Period: _____
1. I _(NAME)___________________ agree to (SPECIFY BEHAVIOR YOU WANT TO CHANGE)
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2. I will begin on _(START DATE)__________ and plan to reach my goal of (SPECIFY FINAL GOAL)
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3. My short term reward will be _______________________________________________.
My overall reward for reaching my final goal will be
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4. I have analyzed the circumstances and consequences of my target behavior and I have
identified the following positive and negative reinforcers that I can alter to change my
behavior:
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5. I will use a journal to record and monitor my progress toward reaching my final goal.
6. I will request that _(NAME OF HELPER)_____________________________ assist me in
reaching my goal to represent a supporter to me when I am in need.
I sign this contract as an indication of my personal commitment to reach my goal.
_(YOUR SIGNATURE)__________________________________
_(DATE)____________
(LIST ANY WAYS IN WHICH YOUR HELPER WILL PARTICIPATE IN YOUR PROGRAM)
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_(HELPER’S SIGNATURE)________________________________________
_(DATE)____________
Benefits I anticipate as a result of this change.
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List any benefits of not changing.
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What will happen if I don’t change?
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Behavior Change Project
Name: ______________________________
Date: _______________
Period: _____
This Behavior Change Project provides you with the opportunity to apply concepts covered in
class toward improving an aspect of your own personal health.
Step 1: Decide on a particular health behavior to change.
Step 2: Complete the Behavior Change Contract to plan, guide and evaluate your progress
toward changing a specific habit that is detrimental to your health.
Step 3: Write a one page, typed paper (double spaced, 12-font), about particular health risks
and benefits associated with the behavior change that you choose. You need to provide at
least two reliable sources to support the claims you make in this paper, as well as cite them in
the paper and reference them on a separate page.
Step 4: Keep a weekly journal describing your progress and pitfalls. Include barriers
encountered, successes, emotional and physical reactions to changes, reactions of others to the
changes, and your comments and feelings about the project.
Step 5: Write an evaluation of your Behavior Change Project by answering the following
questions: (This must also by typed; double spaced, 12-font)
Were you successful in changing a health behavior?
If so, did your timeline and reward system work?
If not, where and why did your plan break down?
How will you maintain your changed behavior?
Step 6: Format your project in this order: cover page, Behavior Change Contract, one page
typed paper on health risks and benefits associated with your behavior change, journal entries
(not needed to be typed), evaluation, and a reference page (also typed). Your Behavior Change
Project is due on _______________. LATE PAPERS WILL NOT BE ACCEPTED! If it is not turned in
on the due date you will receive a 0 for the project.
Behavior Change Project Point Scale
Behavior Change Contract- 4 points
One page paper- 10 points
Weekly journal entries (at least 3 per week)- 5 points
Evaluation- 5 points
References- 3 points
Neatness and organization- 3 points
Total points= 30