See http://www.hhs.gov/opa/familylife/tech_assistance/resources/ami-materials.pdf (PDF, 2 MB) for more information and examples.
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:
As a result of scientific research, we know that addiction is a disease that affects both brain and behavior.