Behavior Change Reflection Form
Use this Behavior Change Reflection Form to thoughtfully assess your progress, challenges, and insights related to your behavior change journey.
What specific behavior did you focus on changing?
*
How long have you been working on this behavior change?
*
Please Select
Less than 1 week
1-2 weeks
3-4 weeks
1-2 months
More than 2 months
How confident are you in your ability to maintain this change?
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Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Please rate your overall progress so far.
*
1
2
3
4
5
Which of the following best describes your motivation level throughout this process?
*
Very high
High
Moderate
Low
Very low
What strategies have you used to support your behavior change?
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Setting specific goals
Tracking progress
Seeking support from others
Using reminders
Rewarding yourself
Other
Please indicate how much you agree with the following statements about your behavior change experience.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel supported in my behavior change effort.
1
2
3
4
5
I have noticed positive results.
6
7
8
9
10
I am motivated to continue.
11
12
13
14
15
I have faced significant challenges.
16
17
18
19
20
What challenges have you encountered during your behavior change effort?
Lack of time
Low motivation
Unclear goals
Limited support
Other
What has helped you stay on track with your behavior change?
What is your next step or goal regarding this behavior change?
Submit Reflection
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