HSCI 533                                                                                        Dr. Robert Huff

Planning for Personal Change Assessment Instrument

The following items are designed to help you focus on one or more changes you may be thinking about making in your personal life. Your responses to these items will help you decide how committed you are to these changes and what factors you will need to consider if you go forward with your change plans. Please take some time to consider the questions below and when you respond to them be open and honest in these. Being honest with yourself about what it is you really want is the first step in making your personal change a reality.

1. What is it about me that I want to change (be very specific)?
   
   
   
   
   
   
2. On what basis have I decided to make this change (i.e. doctor’ advice, friend, family member, personal choice, etc.)?
   
   
   
   
   
   
3. On a scale of 1-10, how important is it to me to make this change? __________
   
   
   
   
   
4. What effect will making this change have on my current lifestyle?
   
   
   
   
   
   
5. How will I keep myself from making this change? (This is your personal sabotage list so please list everything you can think of that you might do)
   
   
   
   
   
   
6. What are the specific activities/cues that trigger the behavior you are trying to change?
   
   
   
   
   
7. Using one of the activities/cues you identified above, diagram the chain of events which lead up to your actually doing the behavior you are trying to change (include your self-talk, physiological feelings, emotional responses, and how you feel after you have done the behavior). There may be many different chains so diagram as many of these as you can.
   
   
   
   
   
   
   Planning for Personal Change    
   
   
8. Looking at one or more of the chains you diagramed above, what steps could you take to break up a link in the sequence of steps leading up to the behavior you want to change?
   
   
   
   
   
9. If you decide to go ahead with your plans for change, what will be the first step you will take to break a link in the chain?
   
   
   
   
   
   
10. When will you start?
    
    
    
    
    
    
11. What support systems/resources will you use to help you make your change?
    
    
    
    
    
    
12. How and when will you reward yourself along the way to achieving the change you want to make?

How are you feeling now about making your behavior change?
(This is your first opportunity to sabotage your change efforts)