Behavior Modification Contract

To print this activity, download it as a pdf file, lab10.pdf

Directions:
Complete the following behavior modification contract, using friends or peers as witnesses. See below for an example of a completed contract.

1. I ____________________________________ (name) agree to make the following behavior change(s): ____________________________________________________________
____________________________________________________________ beginning on ________________________(date).

2. My short-term goal(s) are to:
_____________________________________________________________
_____________________________________________________________ by _________________________________(date).

3. My long-term goal(s) are to:
_____________________________________________________________
_____________________________________________________________

4. I will assess my progress on the desired behavioral change on a regular basis: _______________________ (note how often).

Further, I will report my progress to at least two friends and/or peers on a regular basis.
Signed: ____________________________Date: _______________________
Witness: ___________________________Witness: ____________________

Illustration of Behavior Modification Contract for Smoking Cessation:

Behavior Modification Contract

5. I __________John Doe__________________________ (name) agree to make the following behavior change(s): _____________________________________________________________
beginning on _____May 15, 1999____(date).

6. My short-term goal(s) are to: ___Stop smoking____________________________________________________________________ _____________________________________________by May 15, 1999__________________(date).

7. My long-term goal(s) are to: Remain smoke free during the rest of my life

8. I will assess my progress on the desired behavioral change on a regular basis: ________weekly_______________ (note how often).

Further, I will report my progress to at least two friends and/or peers on a regular basis.
Signed: _______John Doe______________________________ Date: May 1, 1999 Witness: ___Bill Jones____________________ Witness: ___________Linda Williams______