En español
NIDA

Menu

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

Sample Change Plan Worksheet

Ordering Publications

Call 1-877-643-2644 or:
NIDA Drug Pubs

Cite this article

AP style citation

National Institute on Drug Abuse (2012). Sample Change Plan Worksheet. In Resource Guide: Screening for Drug Use in General Medical Settings. Retrieved from http://www.drugabuse.gov/publications/resource-guide/change-plan-worksheet

press ctrl+c to copy