| The changes I want to make during the next 12 weeks are: |
| The most important reasons why I want to make those changes are: |
| The steps I plan to take in changing are: |
| The ways other people can help me are: |
| Some things that might interfere with my plan are: |
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| The changes I want to make during the next 12 months are: |
| The most important reasons why I want to make those changes are: |
| The steps I plan to take in changing are: |
| The ways other people can help me are: |
| Some things that might interfere with my plan are: |