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For EACH change you are considering making, think about each self-assessment area below. We will discuss during our first session.

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Possible Change # ___

What I am thinking about changing: (Be as specific as possible. Reference specific behaviors, emotions, interactions, thoughts, fantasies, etc. that are problematic.)

​What I might try to do to make this change happen:

Why I think this strategy might work. How I have used it before to successfully make changes:

Why I am concerned that this change strategy might not work.

How motivated I am to work on this change. (Rate using the scale below.)

  __________________________________

  1     2     3     4     5     6     7     8     9     10

​Not ready             Unsure                   Ready

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For EACH change you are trying/attempting to make, think about each self-assessment area below. We will discuss during our first session.

Change # ___

What I am trying/attempting to change: (Be as specific as possible. Reference specific behaviors, emotions, interactions, thoughts, fantasies, etc. that are problematic.):

​What I have tried to do to make this change happen:

RESULTS

What I have accomplished so far: (Be as specific as possible. Describe what you observe in changes to emotions, interactions, thoughts, etc.)

What aspects of my change strategy worked:

What aspects of my change strategy did not work:

How motivated I am to continue working on this change. (Rate using the scale below.)

  __________________________________

  1     2     3     4     5     6     7     8     9     10

​Not ready             Unsure                   Ready

self-assessment