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Directions: Using your approved SMART behavior change goal and three short term goals you developed to reach it, complete this two page Behavior Change Contract by thoroughly answering all sections. Electronically sign the contract at the bottom to affirm your commitment to making a healthy behavior change and ask someone who will hold you accountable to witness it.

_____________________________________________________________________________________

My SMART Behavior Change Goal:

Three obstacles to my desired change (current behaviors or situations that could hamper my goal).

1.

2.

3.

Three strategies I will use to overcome the specific obstacles listed above:

1.

2.

3.

Resources I will use to help me reach my behavior change goal. Provide an answer for each one. Note: Include clear details: name of person or facility, location, exact article/book title/website. Think of answers that are relevant and realistic FOR YOU.

a. Witness/Accountability Partner & Relationship:

b. School-based resource:

c. Community-based resource:

d. A book or reputable website link:

In order to make my goal more attainable, I have devised three short term goals. Be sure the check the date ranges provided on the Home page in Canvas. A note on rewards: make the rewards worth striving for and progressive – the first reward is good; the third reward is GREAT!

Short Term Goal 1:

Date Range:

Reward upon Success:

Short Term Goal 2:

Date Range:

Reward upon Success:

Short Term Goal 3 (which is the same as your SMART goal above):

Date Range:

Reward upon Success:

I intend to make a behavior change that will contribute to a healthy life. I will use the strategies and rewards I set to achieve my goals.

Signed: _____________________ Date: _____________________________

Witness: _________________________________ Date: _____________________________

Adapted from Copyright © 2009 Pearson Education Inc.

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