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Resource Guide: Screening for Drug Use in General Medical Settings

Sample 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 plans are:

 

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

 

As my doctor, you can help me keep these changes by:

 

This page was last updated March 2012

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