CHANGE PLAN WORKSHEET

The changes I want to make (or continue making) are:

The reasons why I want to make these changes are:

The steps I plan to take in changing are:

The ways other people can help me are:

I will know that my plan is working if:

Some things that could interfere with my plan are:

What I will do if the plan isn’t working:

CHANGE PLAN WORKSHEET OUTLINE

The changes I want to make (or continue making) are:
List specific areas or ways in which you want to change
Include positive goals (beginning, increasing, improving behavior)

The reasons why I want to make these changes are:
What are some likely consequences of action and inaction?
Which motivations for change seems most important to you?

The steps I plan to take in changing are:
How do you plan to achieve the goals?
Within the general plan, what are some specific first steps you might take?
When, where and how will these steps be taken?
The ways other people can help me are:
List specific ways that others can help support you in your change attempt.
How will you go about eliciting others’ support?

I will know that my plan is working if:
What do you hope will happen as a result of the change?
What benefits can you expect from the change?

Some things that could interfere with my plan are:
Anticipate situations or changes that could undermine the plan.
What could go wrong?

What I will do if the plan isn’t working:
How might you stick with the plan despite the changes?

CHANGE PLAN WORKSHEET

The changes I want to make (or continue making) are:

Stop smoking
Reduce my drinking
Take better care of my kids
The reasons why I want to make these changes are:
Get out of trouble with probation—avoid dirty urines
Take better care of my health
Give my kids a better chance.
The steps I plan to take in changing are:
Keep coming to group and treatment here
Give urines to my PO every week
Spend time each day focusing on my children
Go to my children’s schools to meet with their teachers
Stop using crack, one day at a time
Get a sponsor at NA
Avoid hanging out with people who use
Go to Church.
The ways other people can help me are:
My PO can encourage me when I give a clean urine
My counselor can help me deal with my depression
My group can help me talk about my difficulties in quitting
My mom can care for my kids when I’m working or at treatment
My sponsor can help me when I have a craving
I will know that my plan is working if:
I am not using crack
I am giving clean urines
I am coming to group 8 out of 10 times
I am spending time each day focusing on my children and their needs
I am going to NA 3 times a week
Some things that could interfere with my plan are:
If I get sent back to jail for a positive urine
If I don’t plan ahead for cravings and urges
If I don’t stop hanging with friends who are active in their use
If I quit treatment
What I will do if the plan isn’t working:
Be honest with my counselor and my group and ask for help
Make another plan that takes care of cravings/urges better
Tell my PO I need a residential treatment or more treatment
Refuse to let myself feel like a failure
CODING SHEETS

Questions:
Closed:

Open:

Reflections:
Simple:

Complex:

Summaries:

Change Talk:

Sustain Talk:

Feedback in the Spirit of MI:

“We are trying to cultivate change talk and side step sustain talk”

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